Provider Demographics
NPI:1699822320
Name:HOVERSLAND, JON MIKAL (MD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:MIKAL
Last Name:HOVERSLAND
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 1:240 N TILLOTSON AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-3988
Mailing Address - Country:US
Mailing Address - Phone:765-288-1928
Mailing Address - Fax:
Practice Address - Street 1:100 N TILLOTSON AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-3987
Practice Address - Country:US
Practice Address - Phone:765-288-8770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01063658A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN471400088OtherMEDICARE
IN200872630Medicaid