Provider Demographics
NPI:1235110255
Name:MAIN, JONATHAN D (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:D
Last Name:MAIN
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 1:7401 104TH AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-7845
Mailing Address - Country:US
Mailing Address - Phone:262-764-5595
Mailing Address - Fax:262-764-9314
Practice Address - Street 1:7401 104TH AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-7845
Practice Address - Country:US
Practice Address - Phone:262-764-5595
Practice Address - Fax:262-764-9314
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI38865207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32337800Medicaid
WI32337800Medicaid
WI001032290Medicare ID - Type Unspecified