Provider Demographics
NPI:1548611924
Name:NITZ, JONATHAN (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:NITZ
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 1:2110 W GENEVA RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-6204
Mailing Address - Country:US
Mailing Address - Phone:502-320-4248
Mailing Address - Fax:
Practice Address - Street 1:624 NE GLEN OAK AVE
Practice Address - Street 2:ROOM 2670
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3135
Practice Address - Country:US
Practice Address - Phone:309-655-3971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-27
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.069354208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery