Provider Demographics
NPI:1891959730
Name:WOOLERY, JONATHAN D (MD, MPH, MS)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:D
Last Name:WOOLERY
Suffix:
Gender:M
Credentials:MD, MPH, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22400 BARTON RD # 21-301
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-5030
Mailing Address - Country:US
Mailing Address - Phone:949-378-8250
Mailing Address - Fax:714-539-2131
Practice Address - Street 1:22400 BARTON RD # 21-301
Practice Address - Street 2:
Practice Address - City:GRAND TERRACE
Practice Address - State:CA
Practice Address - Zip Code:92313-5030
Practice Address - Country:US
Practice Address - Phone:949-378-8250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL30139207RC0200X
CAA104883208M00000X, 207PE0004X
KY43599207P00000X, 207PE0004X
OK37062207PE0004X
HI18055207PE0004X
MO2008018595207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2008018595OtherMISSOURI LICENSE