Provider Demographics
NPI:1760639983
Name:BIXBY, JONATHAN CARL (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:CARL
Last Name:BIXBY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MISSION HALL, BOX 0110
Mailing Address - Street 2:550 16TH STREET, 4TH FLOOR
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-2549
Mailing Address - Country:US
Mailing Address - Phone:415-502-2720
Mailing Address - Fax:415-502-7516
Practice Address - Street 1:505 PARNASSUS AVE
Practice Address - Street 2:ROOM M-696, BOX 0110
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-0110
Practice Address - Country:US
Practice Address - Phone:415-502-2720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-19
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301092684208000000X, 208100000X
CAA1271362080S0010X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA127136OtherMEDICAL BOARD OF CALIFORNIA
MI4301092684OtherSTATE LISCENCE