Provider Demographics
NPI:1710934609
Name:JONASON, ANITA T (MD)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:T
Last Name:JONASON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1027 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-3409
Mailing Address - Country:US
Mailing Address - Phone:218-847-5611
Mailing Address - Fax:218-847-0881
Practice Address - Street 1:1027 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3409
Practice Address - Country:US
Practice Address - Phone:218-847-5611
Practice Address - Fax:218-847-0881
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN27043207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNDA9031015651OtherPREFERRED ONE #
MN0105972OtherMEDICA #
MNMN100022OtherLHS/BANNERHEALTH #
MN160883OtherUCARE #
MN937282200Medicaid
MNHP19547OtherHEALTHPARTNERS #
MN6105910OtherMNBS #
MN911075OtherAMERICA'S PPO/ARAZ #
MN6466OtherNDBS #
MN0105973OtherMEDICA #
MN17130Medicaid
MN160883OtherUCARE #
MN937282200Medicaid
MN911075OtherAMERICA'S PPO/ARAZ #