Provider Demographics
NPI:1548239460
Name:JONKMAN, MARITHA ANN (MD)
Entity Type:Individual
Prefix:
First Name:MARITHA
Middle Name:ANN
Last Name:JONKMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARITHA
Other - Middle Name:ANN
Other - Last Name:OLIVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 4699
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-4699
Mailing Address - Country:US
Mailing Address - Phone:765-449-2732
Mailing Address - Fax:765-449-1196
Practice Address - Street 1:3774 BAYLEY DR
Practice Address - Street 2:SUITE B
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-8651
Practice Address - Country:US
Practice Address - Phone:765-807-8180
Practice Address - Fax:765-807-8181
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01053805A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200344140Medicaid
IN200344140Medicaid