Provider Demographics
NPI:1164534566
Name:SUDDARTH, JONATHAN M (DO)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:M
Last Name:SUDDARTH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W HUTCHINGS ST
Mailing Address - Street 2:
Mailing Address - City:WINTERSET
Mailing Address - State:IA
Mailing Address - Zip Code:50273-2104
Mailing Address - Country:US
Mailing Address - Phone:515-462-2373
Mailing Address - Fax:515-462-5132
Practice Address - Street 1:300 W HUTCHINGS ST
Practice Address - Street 2:
Practice Address - City:WINTERSET
Practice Address - State:IA
Practice Address - Zip Code:50273-2104
Practice Address - Country:US
Practice Address - Phone:515-462-2373
Practice Address - Fax:515-462-5132
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3346207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1241489Medicaid
IA01495OtherBCBS
IA01495OtherBCBS
IA1241489Medicaid