Provider Demographics
NPI:1881013118
Name:HALL, JONATHAN R (DO)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:R
Last Name:HALL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 S COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:24605-1640
Mailing Address - Country:US
Mailing Address - Phone:276-326-3376
Mailing Address - Fax:
Practice Address - Street 1:725 S COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:VA
Practice Address - Zip Code:24605-1640
Practice Address - Country:US
Practice Address - Phone:276-326-3376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102204981207R00000X
WV3129207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVP630C113Medicaid