Provider Demographics
NPI:1205028149
Name:BEATTY, JONATHAN A (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:A
Last Name:BEATTY
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 1:407 S 10TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-1269
Mailing Address - Country:US
Mailing Address - Phone:610-639-1117
Mailing Address - Fax:215-764-6447
Practice Address - Street 1:407 S 10TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19147-1269
Practice Address - Country:US
Practice Address - Phone:610-639-1117
Practice Address - Fax:215-764-6447
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-14
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4413082084P2900X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1004961Medicaid