Provider Demographics
NPI:1316280159
Name:GHODASRA, JASON (MD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:GHODASRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1870 SILVER CROSS BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-8646
Mailing Address - Country:US
Mailing Address - Phone:815-462-3474
Mailing Address - Fax:
Practice Address - Street 1:1870 SILVER CROSS BLVD STE 200
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-8646
Practice Address - Country:US
Practice Address - Phone:815-462-3474
Practice Address - Fax:815-462-1032
Is Sole Proprietor?:No
Enumeration Date:2013-03-29
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-150218207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036150218OtherILLINOIS PHYSICIAN AND SURGEON LICENSE