Basic Information
| Provider Information | |||||||||
| NPI: | 1194791368 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SOFFA | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | IAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27450 SCHOENHERR RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480886683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865827550 | ||||||||
| FaxNumber: | 5865827515 | ||||||||
| Practice Location | |||||||||
| Address1: | 27450 SCHOENHERR RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480886683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865827550 | ||||||||
| FaxNumber: | 5865827515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2006 | ||||||||
| LastUpdateDate: | 08/17/2010 | ||||||||
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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 | 207Q00000X | 5101015353 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 53150194353 | 01 | MI | CONTROLLED SUBSTANCE | OTHER | 4828059 | 05 | MI | MEDICAID | 5183594 | 05 | MI | MEDICAID |