Provider Demographics
NPI:1689644866
Name:HUMPHREY, JONATHAN B C (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:B C
Last Name:HUMPHREY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:4165 BLACKHAWK PLAZA CIR
Mailing Address - Street 2:#100
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94506-4904
Mailing Address - Country:US
Mailing Address - Phone:925-736-7070
Mailing Address - Fax:925-736-7075
Practice Address - Street 1:4165 BLACKHAWK PLAZA CIR
Practice Address - Street 2:#100
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94506-4904
Practice Address - Country:US
Practice Address - Phone:925-736-7070
Practice Address - Fax:925-736-7075
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-23
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG66292207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ00501ZMedicare ID - Type Unspecified
CAF14976Medicare UPIN