Basic Information
| Provider Information | |||||||||
| NPI: | 1770554982 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DELLA VECCHIA | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 408 N STATE OF FRANKLIN RD | ||||||||
| Address2: | SUITE 24 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376046089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234311810 | ||||||||
| FaxNumber: | 4234311811 | ||||||||
| Practice Location | |||||||||
| Address1: | 408 N STATE OF FRANKLIN RD | ||||||||
| Address2: | SUITE 24 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376046089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234311810 | ||||||||
| FaxNumber: | 4234311811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2006 | ||||||||
| LastUpdateDate: | 02/01/2017 | ||||||||
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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 | 207R00000X | 200400663 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 47972 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 31318 | SC | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1362H | 01 | NC | BCBS | OTHER | 1770554982 | 05 | VA | MEDICAID | 1527494 | 05 | TN | MEDICAID | 891362H | 05 | NC | MEDICAID | 7100194900 | 05 | KY | MEDICAID | P00213994 | 01 | NC | RAILROAD MEDICARE | OTHER |