Provider Demographics
NPI:1154300770
Name:HART, JONATHAN D (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:D
Last Name:HART
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 1:2605 E CREEKS EDGE DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-8368
Mailing Address - Country:US
Mailing Address - Phone:812-355-2300
Mailing Address - Fax:812-355-2316
Practice Address - Street 1:2605 E CREEKS EDGE DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-8368
Practice Address - Country:US
Practice Address - Phone:812-355-2300
Practice Address - Fax:812-355-2316
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01039715207P00000X
IN01039715A207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200008900Medicaid
INM400021747Medicare PIN
INE52045Medicare UPIN
IN252630RMedicare PIN