Provider Demographics
NPI:1467466482
Name:TRAVIS, JONATHAN E (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:E
Last Name:TRAVIS
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:PO BOX 3222
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-0293
Mailing Address - Country:US
Mailing Address - Phone:707-261-7822
Mailing Address - Fax:707-256-3508
Practice Address - Street 1:1 MADRONE ST
Practice Address - Street 2:
Practice Address - City:WILLITS
Practice Address - State:CA
Practice Address - Zip Code:95490-4225
Practice Address - Country:US
Practice Address - Phone:707-456-3093
Practice Address - Fax:707-256-3508
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG688782085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G688780Medicaid
CA00G688780Medicaid
00G688781Medicare ID - Type UnspecifiedINDIVIDUAL PROVIDER ID