Provider Demographics
NPI:1396961983
Name:BOWERSOCK, JASON D (MD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:D
Last Name:BOWERSOCK
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 1:830 W HIGH ST STE 360
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45801-3985
Mailing Address - Country:US
Mailing Address - Phone:419-227-7117
Mailing Address - Fax:419-227-2848
Practice Address - Street 1:830 W HIGH ST
Practice Address - Street 2:SUITE 360
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801
Practice Address - Country:US
Practice Address - Phone:419-227-7117
Practice Address - Fax:419-227-2848
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35089145208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2737417Medicaid
OH4292081Medicare PIN