Provider Demographics
NPI:1588649289
Name:PARK, JONATHON LEX (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHON
Middle Name:LEX
Last Name:PARK
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 1:1900 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-0000
Mailing Address - Country:US
Mailing Address - Phone:541-267-5151
Mailing Address - Fax:541-266-4507
Practice Address - Street 1:110 10TH ST SE
Practice Address - Street 2:
Practice Address - City:BANDON
Practice Address - State:OR
Practice Address - Zip Code:97411-9157
Practice Address - Country:US
Practice Address - Phone:541-347-2313
Practice Address - Fax:541-347-2015
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23699207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR0000WFBTVOtherMEDICARE GROUP PIN NUMBER
OR1407812365OtherNBMC GROUP NPI NUMBER
OR93063551OtherGROUP TAX ID NUMBER
ORCD8723OtherRR MEDICARE GROUP NUMBER
OR080182358OtherRR MEDICARE PTAN NUMBER
OR286887Medicaid
ORR0000WFBTVOtherMEDICARE GROUP PIN NUMBER
OR286887Medicaid
OR0577260001Medicare NSC