Basic Information
| Provider Information | |||||||||
| NPI: | 1174745962 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOARDMAN | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | ANDREW | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10000 W COLONIAL DR | ||||||||
| Address2: | SUITE 288 | ||||||||
| City: | OCOEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347613400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4075213600 | ||||||||
| FaxNumber: | 4075213603 | ||||||||
| Practice Location | |||||||||
| Address1: | 1804 OAKLEY SEAVER DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | CLERMONT | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347111925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522432622 | ||||||||
| FaxNumber: | 3522436277 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 02/01/2012 | ||||||||
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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 | 208600000X | ME92559 | FL | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 03417 | 01 | FL | BCBS PROVIDER NUMBER | OTHER | 7460692 | 01 | FL | AETNA PROVIDER NUMBER | OTHER |