Provider Demographics
NPI:1861753485
Name:HABECK, JASON MARK (MD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:MARK
Last Name:HABECK
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 1:123 HOSPITAL DR
Mailing Address - Street 2:STE 1008
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53098-3320
Mailing Address - Country:US
Mailing Address - Phone:920-206-6500
Mailing Address - Fax:920-261-4013
Practice Address - Street 1:13020 N TELECOM PKWY
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33637-0925
Practice Address - Country:US
Practice Address - Phone:813-978-9700
Practice Address - Fax:813-558-6187
Is Sole Proprietor?:No
Enumeration Date:2012-05-30
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301100883207X00000X, 390200000X
FLME130378207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLWC162OtherBCBS
FLJA244ZOtherMEDICARE
FL020408900Medicaid