Basic Information
| Provider Information | |||||||||
| NPI: | 1508003971 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POTHAST | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18109 PRINCE PHILIP DR | ||||||||
| Address2: | SUITE 155 | ||||||||
| City: | OLNEY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208321519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3015707415 | ||||||||
| FaxNumber: | 3015707416 | ||||||||
| Practice Location | |||||||||
| Address1: | 18109 PRINCE PHILIP DR | ||||||||
| Address2: | SUITE 155 | ||||||||
| City: | OLNEY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208321519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3015707415 | ||||||||
| FaxNumber: | 3015707416 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2009 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 2081S0010X | D0078451 | MD | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0308871 | 05 | NJ | MEDICAID | 102738394 | 05 | PA | MEDICAID |