Provider Demographics
NPI:1609832690
Name:ISOM, JOHNATHAN MILTON (MD, MBA)
Entity Type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:MILTON
Last Name:ISOM
Suffix:
Gender:M
Credentials:MD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 400
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38302-0400
Mailing Address - Country:US
Mailing Address - Phone:731-425-5752
Mailing Address - Fax:731-422-5743
Practice Address - Street 1:5744 NANJACK CIR
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38115-2061
Practice Address - Country:US
Practice Address - Phone:901-797-9711
Practice Address - Fax:901-797-9771
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN20634207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3030932OtherBCBS
MS302I059810OtherMEDICARE PTAN
B89831Medicare UPIN
TN3054051Medicare ID - Type Unspecified