Provider Demographics
NPI:1740218247
Name:MOREY, JONATHAN BLAKE (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:BLAKE
Last Name:MOREY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 SOUTH GIBSON STREET
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:WI
Mailing Address - Zip Code:54451-1622
Mailing Address - Country:US
Mailing Address - Phone:715-748-2121
Mailing Address - Fax:
Practice Address - Street 1:1511 RAILROAD AVENUE
Practice Address - Street 2:
Practice Address - City:PRENTICE
Practice Address - State:WI
Practice Address - Zip Code:54556-0140
Practice Address - Country:US
Practice Address - Phone:715-428-2521
Practice Address - Fax:715-428-2522
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI23165207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIB55211Medicare UPIN
WI30355700Medicare ID - Type Unspecified