Provider Demographics
NPI:1508839556
Name:YODER, JONATHAN EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:EDWARD
Last Name:YODER
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 1:402 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:ATMORE
Mailing Address - State:AL
Mailing Address - Zip Code:36502-3004
Mailing Address - Country:US
Mailing Address - Phone:251-368-7974
Mailing Address - Fax:251-368-5973
Practice Address - Street 1:402 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:ATMORE
Practice Address - State:AL
Practice Address - Zip Code:36502-3004
Practice Address - Country:US
Practice Address - Phone:251-368-7974
Practice Address - Fax:251-368-5973
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-09
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL11637207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000010182Medicaid
ALC72925Medicare UPIN
AL000010182Medicare PIN