Provider Demographics
NPI:1528059391
Name:SUPPAN, JASON NORBERT (DPM)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:NORBERT
Last Name:SUPPAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6200 PLEASANT AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-4671
Mailing Address - Country:US
Mailing Address - Phone:330-682-6070
Mailing Address - Fax:330-684-2822
Practice Address - Street 1:1710 PARADISE RD
Practice Address - Street 2:
Practice Address - City:ORRVILLE
Practice Address - State:OH
Practice Address - Zip Code:44667-9418
Practice Address - Country:US
Practice Address - Phone:330-682-6070
Practice Address - Fax:330-684-2822
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36-00-3017-S213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1528059391OtherNPI
OH2012842Medicaid
OH2012842Medicaid
U62274Medicare UPIN
OH0201430001Medicare NSC