Provider Demographics
NPI:1124009287
Name:SURDAM, JONATHAN W (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:W
Last Name:SURDAM
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 1:583 S CLARIZZ BLVD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-5515
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1302 S ROGERS ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-4752
Practice Address - Country:US
Practice Address - Phone:812-333-2663
Practice Address - Fax:812-676-4131
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01058877174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00146258OtherRAILROAD MEDICARE
IN200479570Medicaid
INH90720Medicare UPIN
IN199290DMedicare PIN