Provider Demographics
NPI:1053526210
Name:GLOVER, JASON M (MD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:M
Last Name:GLOVER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2801 N GANTENBEIN AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1623
Mailing Address - Country:US
Mailing Address - Phone:503-279-9300
Mailing Address - Fax:503-276-9351
Practice Address - Street 1:2801 N GANTENBEIN AVE FL 3
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1623
Practice Address - Country:US
Practice Address - Phone:503-279-9300
Practice Address - Fax:503-276-9351
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101242313208000000X
VA0116016654390200000X
ORMD1501952080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1053526210Medicaid