Individual
JASON S SO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
350 PELLER RD, LAKE GENEVA, WI 53147-4543
(262) 245-0221
(262) 249-0633
Mailing address
350 PELLER RD, LAKE GENEVA, WI 53147-4543
(262) 245-0221
(262) 249-0633
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
036119919
IL
207Q00000X
Family Medicine Physician
Primary
63015-21
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1508078643
BCBSWI
WI
05
—
1508078643
—
WI
01
—
SOJAS
MERCYCARE INSURANCE
WI
Enumeration date
05/03/2007
Last updated
08/29/2019
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