Provider Demographics
NPI:1518320837
Name:PROULX, JONATHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:PROULX
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 911
Mailing Address - Street 2:
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05302-0911
Mailing Address - Country:US
Mailing Address - Phone:207-303-3200
Mailing Address - Fax:207-250-2140
Practice Address - Street 1:155 BORTHWICK AVE STE C
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-7156
Practice Address - Country:US
Practice Address - Phone:603-828-0100
Practice Address - Fax:603-828-0111
Is Sole Proprietor?:No
Enumeration Date:2016-04-04
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD26071207RH0003X
NH22815207RH0003X, 207RH0003X
MA279244390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program