Provider Demographics
NPI:1962728253
Name:GEORGE, JASON JOSEPH
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:JOSEPH
Last Name:GEORGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37799 PROFESSIONAL CENTER DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-1153
Mailing Address - Country:US
Mailing Address - Phone:734-464-3251
Mailing Address - Fax:
Practice Address - Street 1:37799 PROFESSIONAL CENTER DR
Practice Address - Street 2:SUITE 105
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-1153
Practice Address - Country:US
Practice Address - Phone:734-464-3251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-13
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI430102640207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program