Provider Demographics
NPI:1477197853
Name:OPHEIM, JONATHAN (RPH)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:OPHEIM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W9897 HICKORY LN
Mailing Address - Street 2:
Mailing Address - City:PICKETT
Mailing Address - State:WI
Mailing Address - Zip Code:54964-9600
Mailing Address - Country:US
Mailing Address - Phone:920-872-0123
Mailing Address - Fax:
Practice Address - Street 1:W9897 HICKORY LN
Practice Address - Street 2:
Practice Address - City:PICKETT
Practice Address - State:WI
Practice Address - Zip Code:54964-9600
Practice Address - Country:US
Practice Address - Phone:920-872-0123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-29
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19985-40208U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208U00000XAllopathic & Osteopathic PhysiciansClinical Pharmacology