Provider Demographics
NPI:1366507709
Name:ROE, JONATHAN D (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:D
Last Name:ROE
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 1:3400 DEERFIELD DR
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546-3557
Mailing Address - Country:US
Mailing Address - Phone:608-314-3600
Mailing Address - Fax:608-314-3601
Practice Address - Street 1:3400 DEERFIELD DR
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53546-3557
Practice Address - Country:US
Practice Address - Phone:608-314-3600
Practice Address - Fax:608-314-3601
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI35916-20208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32061100Medicaid
IL347845572 1Medicaid
WIROEJONOtherMERCYCARE INSURANCE
F88320Medicare UPIN
WI32061100Medicaid