Provider Demographics
NPI:1902908544
Name:OHR, JASON T (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:T
Last Name:OHR
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 1:800 MERCY DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-3128
Mailing Address - Country:US
Mailing Address - Phone:712-328-5350
Mailing Address - Fax:712-328-5354
Practice Address - Street 1:800 MERCY DR
Practice Address - Street 2:SUITE 110
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-3128
Practice Address - Country:US
Practice Address - Phone:712-328-5350
Practice Address - Fax:712-328-5354
Is Sole Proprietor?:No
Enumeration Date:2006-09-03
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA26933174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2274787Medicaid
IA27478Medicare PIN
IAE07352Medicare UPIN
IA27478Medicare ID - Type Unspecified