Provider Demographics
NPI:1922092295
Name:GROTAS, JASON A (MD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:A
Last Name:GROTAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 CENTRAL AVE STE 207
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:NY
Mailing Address - Zip Code:11559-8507
Mailing Address - Country:US
Mailing Address - Phone:516-239-8585
Mailing Address - Fax:516-239-8529
Practice Address - Street 1:290 CENTRAL AVE STE 207
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:NY
Practice Address - Zip Code:11559-8507
Practice Address - Country:US
Practice Address - Phone:516-239-8585
Practice Address - Fax:516-239-8529
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-01
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNY235437208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY026631Medicaid
NYI40411Medicare UPIN
NY026631Medicaid