Basic Information
| Provider Information | |||||||||
| NPI: | 1245228675 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SCHOONDYKE | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | WAYNE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5159 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376025159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239264468 | ||||||||
| FaxNumber: | 4239284838 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 N STATE OF FRANKLIN RD STE 2 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376043645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239264468 | ||||||||
| FaxNumber: | 4239284838 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2005 | ||||||||
| LastUpdateDate: | 02/12/2018 | ||||||||
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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 | 207RC0000X | 36563 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 101237133 | VA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 010113652 | 05 | VA | MEDICAID |