Provider Demographics
NPI:1831290279
Name:STAUB, JONATHAN SIMON (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:SIMON
Last Name:STAUB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7307
Mailing Address - Country:US
Mailing Address - Phone:910-341-3300
Mailing Address - Fax:910-251-8896
Practice Address - Street 1:1202 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7307
Practice Address - Country:US
Practice Address - Phone:910-341-3300
Practice Address - Fax:910-251-8896
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9400646207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC110123217OtherRAILROAD MEDICARE
NC8979424Medicaid
NC79424OtherBCBS NC
NC110123217OtherRAILROAD MEDICARE
NCC33340Medicare UPIN
NC2198745BMedicare PIN