Provider Demographics
NPI:1275502510
Name:LENZEN, JONATHAN M (MD, FCCP)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:M
Last Name:LENZEN
Suffix:
Gender:M
Credentials:MD, FCCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2210 WILBORN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-1630
Mailing Address - Country:US
Mailing Address - Phone:434-575-5864
Mailing Address - Fax:434-575-8929
Practice Address - Street 1:2210 WILBORN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-1630
Practice Address - Country:US
Practice Address - Phone:434-575-5864
Practice Address - Fax:434-575-8929
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101048561207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006013996Medicaid
VA032464OtherANTHEM BC PROVIDER #
NC890595YMedicaid
NC51700OtherBC/BS NC PROVIDER #
NC2317122OtherMEDICARE-GROUP #
VA290000139Medicare ID - Type Unspecified
VA006013996Medicaid
NC2205555Medicare ID - Type Unspecified