Provider Demographics
NPI:1669455390
Name:MONSON, JEDIDIAH M (MD)
Entity Type:Individual
Prefix:
First Name:JEDIDIAH
Middle Name:M
Last Name:MONSON
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 1:104 WOODMONT BLVD STE 500
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37205-2245
Mailing Address - Country:US
Mailing Address - Phone:615-252-7212
Mailing Address - Fax:
Practice Address - Street 1:7130 N MILLBROOK AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3347
Practice Address - Country:US
Practice Address - Phone:559-326-1222
Practice Address - Fax:559-326-1225
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG832752085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G832750OtherBLUE SHIELD CA PROVIDER #
CA00G832750Medicaid
CA5795635OtherAETNA PROVIDER #
CA1489286OtherCIGNA PROVIDER #
CA00G832750Medicaid
CA00G832756Medicare PIN