Basic Information
| Provider Information | |||||||||
| NPI: | 1457573974 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLEEKER | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5074 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571175074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053286585 | ||||||||
| FaxNumber: | 6053286512 | ||||||||
| Practice Location | |||||||||
| Address1: | 1309 W 17TH ST | ||||||||
| Address2: | STE 101 | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571044663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053288000 | ||||||||
| FaxNumber: | 6053288001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 04/29/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0101244302 | VA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0003X | 104308 | MN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0003X | 52164 | MN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 390200000X | 0116017474 | VA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RH0003X | 8325 | SD | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | P00813442 | 01 | MN | RAILROAD MEDICARE | OTHER | ENROLLED | 05 | MN | MEDICAID | 1457573974 | 05 | VA | MEDICAID |