Provider Demographics
NPI:1639411325
Name:SCRAFFORD, JONATHAN DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:DAVID
Last Name:SCRAFFORD
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 1:1515 S CLIFTON AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67218-2900
Mailing Address - Country:US
Mailing Address - Phone:316-636-1550
Mailing Address - Fax:316-636-1569
Practice Address - Street 1:1515 S CLIFTON AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-2900
Practice Address - Country:US
Practice Address - Phone:316-636-1550
Practice Address - Fax:316-636-1569
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-20
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KS04-39512207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201157750AMedicaid