Provider Demographics
NPI:1275876971
Name:LONGORIA, JONATHAN JACOB
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:JACOB
Last Name:LONGORIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3046
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-0746
Mailing Address - Country:US
Mailing Address - Phone:956-632-4000
Mailing Address - Fax:956-961-4286
Practice Address - Street 1:301 W EXPRESSWAY 83
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78503-3045
Practice Address - Country:US
Practice Address - Phone:956-632-4000
Practice Address - Fax:956-961-4286
Is Sole Proprietor?:No
Enumeration Date:2013-04-01
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ9187208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3714297-01Medicaid