Provider Demographics
NPI:1356332373
Name:UMLAUF, JON THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:THOMAS
Last Name:UMLAUF
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 1:4647 ZION AVE
Mailing Address - Street 2:NUCLEAR MEDICINE DEPARTMENT
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-2507
Mailing Address - Country:US
Mailing Address - Phone:619-528-6567
Mailing Address - Fax:
Practice Address - Street 1:4647 ZION AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-2507
Practice Address - Country:US
Practice Address - Phone:206-616-5781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA56685207Q00000X, 2083A0100X, 208D00000X
WAMD00046429207U00000X
CAG89012207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN