Provider Demographics
NPI:1689076093
Name:MOAYYAD, JONATHAN P (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:P
Last Name:MOAYYAD
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 1:1 PRESTIGE PL STE 550
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-6115
Mailing Address - Country:US
Mailing Address - Phone:937-762-1310
Mailing Address - Fax:937-522-8493
Practice Address - Street 1:3525 PENTAGON BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45429-1226
Practice Address - Country:US
Practice Address - Phone:937-702-4060
Practice Address - Fax:937-702-4069
Is Sole Proprietor?:No
Enumeration Date:2014-09-17
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.1371682085R0001X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0370544Medicaid