Provider Demographics
NPI:1033537212
Name:RAYBURN, JONATHAN HS (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:HS
Last Name:RAYBURN
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 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-261-1600
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:1 LINCOLN PKWY STE 103
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-3261
Practice Address - Country:US
Practice Address - Phone:601-261-1600
Practice Address - Fax:601-264-5133
Is Sole Proprietor?:No
Enumeration Date:2014-04-03
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS27015207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08820253Medicaid