Provider Demographics
NPI:1750306395
Name:CHRISTIANSEN, JONATHAN MARK (OD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:MARK
Last Name:CHRISTIANSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1196 BROCKLEY CROSS ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89002-3362
Mailing Address - Country:US
Mailing Address - Phone:714-356-8451
Mailing Address - Fax:
Practice Address - Street 1:4485 S PECOS RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-5029
Practice Address - Country:US
Practice Address - Phone:702-737-0097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV550152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV09871Medicare UPIN