Provider Demographics
NPI:1417196601
Name:ELI-PHILLIPS, JONATHAN GABRIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:GABRIEL
Last Name:ELI-PHILLIPS
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 1:1680 DIAGONAL RD
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:56187-1008
Mailing Address - Country:US
Mailing Address - Phone:507-372-3800
Mailing Address - Fax:507-372-3393
Practice Address - Street 1:1018 6TH AVE
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:MN
Practice Address - Zip Code:56187
Practice Address - Country:US
Practice Address - Phone:507-372-3800
Practice Address - Fax:507-372-3806
Is Sole Proprietor?:No
Enumeration Date:2009-02-11
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY234997207V00000X, 207V00000X
PAMD440898207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04034680Medicaid
NYJ400195165OtherPTAN