Basic Information
| Provider Information | |||||||||
| NPI: | 1659538197 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURRELL | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | RAY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14100 SAN PEDRO AVE STE 412 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782322009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102818669 | ||||||||
| FaxNumber: | 2103145044 | ||||||||
| Practice Location | |||||||||
| Address1: | 1248 AUSTIN HWY STE 220 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782094867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109811920 | ||||||||
| FaxNumber: | 2103145044 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2008 | ||||||||
| LastUpdateDate: | 07/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | MD465526 | PA | N | Allopathic & Osteopathic Physicians | General Practice | 208000000X | 67978 | WI | N | Allopathic & Osteopathic Physicians | Pediatrics | 208D00000X | N6201 | TX | N | Allopathic & Osteopathic Physicians | General Practice | 208D00000X | 55939 | TN | N | Allopathic & Osteopathic Physicians | General Practice | 208000000X | N6201 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1659538197 | 05 | WI | MEDICAID |