Provider Demographics
NPI:1477710127
Name:BLEVINS, JONATHAN WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:WILLIAM
Last Name:BLEVINS
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 18977
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-0550
Mailing Address - Country:US
Mailing Address - Phone:949-263-8620
Mailing Address - Fax:800-409-7005
Practice Address - Street 1:39000 BOB HOPE DR DEPT OF
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-3221
Practice Address - Country:US
Practice Address - Phone:949-263-8620
Practice Address - Fax:800-409-7005
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-20
Last Update Date:2017-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT1890542085R0202X
CAA1177642085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1477710127Medicaid
CA00A1177640OtherBC/BS OF CA
CACA131381Medicare PIN