Provider Demographics
NPI:1861481202
Name:DETRICK, JONATHAN MARION (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:MARION
Last Name:DETRICK
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 1:5757 MONCLOVA RD
Mailing Address - Street 2:SUITE 14
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-1863
Mailing Address - Country:US
Mailing Address - Phone:419-893-3316
Mailing Address - Fax:419-893-2320
Practice Address - Street 1:5757 MONCLOVA RD
Practice Address - Street 2:SUITE 14
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1863
Practice Address - Country:US
Practice Address - Phone:419-893-3316
Practice Address - Fax:419-893-2320
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35043922207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCB3101OtherRAILROAD MEDICARE
OH0513331Medicaid
OH0542071Medicare ID - Type Unspecified
OHA80779Medicare UPIN