Provider Demographics
NPI:1386676104
Name:RICHARD, JONATHAN PATRICK (MD, PA)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:PATRICK
Last Name:RICHARD
Suffix:
Gender:M
Credentials:MD, PA
Other - Prefix:DR
Other - First Name:JONATHAN
Other - Middle Name:
Other - Last Name:RICHARD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, PA
Mailing Address - Street 1:5009 THOMPSON TERRACE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034
Mailing Address - Country:US
Mailing Address - Phone:817-581-6800
Mailing Address - Fax:817-581-6080
Practice Address - Street 1:5009 THOMPSON TER
Practice Address - Street 2:SUITE 102
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-5850
Practice Address - Country:US
Practice Address - Phone:817-581-6800
Practice Address - Fax:817-581-6080
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG3730207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00B39DMedicare ID - Type Unspecified
TXC21052Medicare UPIN