Provider Demographics
NPI:1790744704
Name:THYGESON, JONATHAN ERIC (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ERIC
Last Name:THYGESON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:E
Other - Last Name:THYGESON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:755 UNIVERSITY AVENUE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825
Mailing Address - Country:US
Mailing Address - Phone:916-924-8754
Mailing Address - Fax:916-924-1739
Practice Address - Street 1:755 UNIVERSITY AVENUE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825
Practice Address - Country:US
Practice Address - Phone:916-924-8754
Practice Address - Fax:916-924-1739
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-20
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA75063208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD407017800Medicaid
MD75859903OtherBLUE SHIELD
MD761LK894Medicare PIN