Provider Demographics
NPI:1902119373
Name:JASON CORMIER MD PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:JASON CORMIER MD PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:CORMIER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-235-7743
Mailing Address - Street 1:PO BOX 82441
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70598-2441
Mailing Address - Country:US
Mailing Address - Phone:337-235-7743
Mailing Address - Fax:
Practice Address - Street 1:4906 AMBASSADOR CAFFERY PKWY
Practice Address - Street 2:SUITE 1302
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-6962
Practice Address - Country:US
Practice Address - Phone:337-235-7743
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-14
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA203951207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty