Basic Information
| Provider Information | |||||||||
| NPI: | 1851718985 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JONAS | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | NATHAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 E JEFFERSON ST | ||||||||
| Address2: | |||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208524908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2025797105 | ||||||||
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| Practice Location | |||||||||
| Address1: | 510 S KINGSHIGHWAY BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143627200 | ||||||||
| FaxNumber: | 3147474189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2014 | ||||||||
| LastUpdateDate: | 02/04/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 2019009764 | MO | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 200067602 | 05 | MO | MEDICAID | ENROLLED | 05 | IL | MEDICAID |