Provider Demographics
NPI:1376595066
Name:STATE, JONATHON P (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHON
Middle Name:P
Last Name:STATE
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 1:757 VINEWOOD
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009
Mailing Address - Country:US
Mailing Address - Phone:248-644-6029
Mailing Address - Fax:519-258-7896
Practice Address - Street 1:757 VINEWOOD
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009
Practice Address - Country:US
Practice Address - Phone:248-644-6029
Practice Address - Fax:519-258-7896
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301074553207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301074553OtherPHYSICIAN LICENSE
MIC7104OtherMCARE
MICC3713OtherRR MEDICARE
MI127456OtherMERCY CARE CHOICES
MI700H21076OtherBCBSM
MI1591463OtherCIGNA
MI1730121OtherUHC
MI4120366Medicaid
MI5228630OtherAETNA
MI700H21076OtherBCBSM
MICC3713OtherRR MEDICARE
MI5228630OtherAETNA