Provider Demographics
NPI:1477846871
Name:WALGAMA, JONATHAN PIERCE (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:PIERCE
Last Name:WALGAMA
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 1:3209 4TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-5170
Mailing Address - Country:US
Mailing Address - Phone:903-757-2020
Mailing Address - Fax:903-757-4665
Practice Address - Street 1:3209 N 4TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-5171
Practice Address - Country:US
Practice Address - Phone:903-757-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-18
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ3122207W00000X
OK29170207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX346191501Medicaid