Provider Demographics
NPI:1285677294
Name:SCRENOCK, JONATHAN D (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:D
Last Name:SCRENOCK
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 1:120 CYPRESS EDGE DR STE 204
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-8454
Mailing Address - Country:US
Mailing Address - Phone:386-586-4428
Mailing Address - Fax:386-586-4432
Practice Address - Street 1:120 CYPRESS EDGE DR STE 204
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-8454
Practice Address - Country:US
Practice Address - Phone:386-586-4428
Practice Address - Fax:386-586-4432
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME120275207Q00000X
WI40243207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIH07881Medicare UPIN