Provider Demographics
NPI:1548374325
Name:GERBOC, JASON L (DO)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:L
Last Name:GERBOC
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 WATERMAN WAY
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-5229
Mailing Address - Country:US
Mailing Address - Phone:352-343-2364
Mailing Address - Fax:352-343-0548
Practice Address - Street 1:1210 WATERMAN WAY
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-5229
Practice Address - Country:US
Practice Address - Phone:352-343-2364
Practice Address - Fax:352-343-0548
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS012897208800000X
FLOS12668208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2392880000OtherKEYSTONE IBC
PAP00226465OtherRAILROAD MEDICARE
PA101228162 0002Medicaid
PAP01092454OtherRAILROAD MEDICARE
PA1012281620001Medicaid
PA1724365OtherHIGHMARK BLUE SHIELD
PA8460478OtherAETNA HMO
PA1724365OtherPERSONAL CHOICE
PA8460478OtherAETNA NON HMO
PAP01092454OtherRAILROAD MEDICARE
PA8460478OtherAETNA NON HMO
PA1724365OtherHIGHMARK BLUE SHIELD