Basic Information
Provider Information | |||||||||
NPI: | 1891285235 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SOTZEN | ||||||||
FirstName: | JASON | ||||||||
MiddleName: | R | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1804 VIOLA DR | ||||||||
Address2: |   | ||||||||
City: | ORTONVILLE | ||||||||
State: | MI | ||||||||
PostalCode: | 484628847 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2484213202 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2256 W HILL RD | ||||||||
Address2: |   | ||||||||
City: | FLINT | ||||||||
State: | MI | ||||||||
PostalCode: | 485074655 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8102497546 | ||||||||
FaxNumber: | 7344640335 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/11/2018 | ||||||||
LastUpdateDate: | 07/11/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/11/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 4301506266 | MI | Y |   | Allopathic & Osteopathic Physicians | Dermatology |   | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   |
ID Information
ID | Type | State | Issuer | Description | 1891285235 | 05 | MI |   | MEDICAID |