Provider Demographics
NPI:1609840941
Name:PAINE, JONATHAN T (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:T
Last Name:PAINE
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 1:1305 VALENTINE ST
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3127
Mailing Address - Country:US
Mailing Address - Phone:321-727-2468
Mailing Address - Fax:321-952-0163
Practice Address - Street 1:1305 VALENTINE ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3127
Practice Address - Country:US
Practice Address - Phone:321-727-2468
Practice Address - Fax:321-952-0163
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0050830207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL03944OtherBLUE CROSS BLUE SHIELD, F
FL0470639OtherAETNA HMO
FL4039014OtherAETNA PPO
FL6656062002OtherCIGNA
FL6656062002OtherCIGNA
FL03944ZMedicare ID - Type Unspecified