Provider Demographics
NPI:1033113055
Name:PUGMIRE, JONATHAN EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:EDWARD
Last Name:PUGMIRE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 JASON ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-2750
Mailing Address - Country:US
Mailing Address - Phone:503-581-8636
Mailing Address - Fax:503-581-1237
Practice Address - Street 1:633 JASON ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-2750
Practice Address - Country:US
Practice Address - Phone:503-581-8636
Practice Address - Fax:503-581-1237
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD 23534207VG0400X, 207VX0000X
WAMD60636844207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR286501Medicaid
OR286501Medicaid
ORR115205Medicare ID - Type Unspecified