Basic Information
| Provider Information | |||||||||
| NPI: | 1063574515 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEBER | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | MEADE | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 702 RUSSELL AVENUE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | GAITHERSBURG | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208772606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3019483668 | ||||||||
| FaxNumber: | 3019267787 | ||||||||
| Practice Location | |||||||||
| Address1: | 702 RUSSELL AVENUE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | GAITHERSBURG | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208772606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3019483668 | ||||||||
| FaxNumber: | 3019267787 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 04/07/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 01365 | MD | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213ES0103X | 01365 | MD | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 409152300 | 05 | MD | MEDICAID |