Basic Information
| Provider Information | |||||||||
| NPI: | 1588649289 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | JONATHON | ||||||||
| MiddleName: | LEX | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 WOODLAND DR | ||||||||
| Address2: | |||||||||
| City: | COOS BAY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974200000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412675151 | ||||||||
| FaxNumber: | 5412664507 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 10TH ST SE | ||||||||
| Address2: | |||||||||
| City: | BANDON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974119157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413472313 | ||||||||
| FaxNumber: | 5413472015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2005 | ||||||||
| LastUpdateDate: | 10/09/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD23699 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | R0000WFBTV | 01 | OR | MEDICARE GROUP PIN NUMBER | OTHER | 1407812365 | 01 | OR | NBMC GROUP NPI NUMBER | OTHER | 93063551 | 01 | OR | GROUP TAX ID NUMBER | OTHER | CD8723 | 01 | OR | RR MEDICARE GROUP NUMBER | OTHER | 080182358 | 01 | OR | RR MEDICARE PTAN NUMBER | OTHER | 286887 | 05 | OR | MEDICAID |