Provider Demographics
NPI:1932101466
Name:JAMESON, THERON QUENTIN (DO)
Entity Type:Individual
Prefix:DR
First Name:THERON
Middle Name:QUENTIN
Last Name:JAMESON
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:PO BOX 540
Mailing Address - Street 2:
Mailing Address - City:WEST BURLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52655
Mailing Address - Country:US
Mailing Address - Phone:319-768-4970
Mailing Address - Fax:319-768-4975
Practice Address - Street 1:550 REDSTONE AVE W STE 370
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-6429
Practice Address - Country:US
Practice Address - Phone:850-306-2710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2024-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03133174400000X, 207X00000X
FLOS19000207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAP00688747OtherRR MEDICARE
IA1932101466Medicaid
IAI4373021Medicare PIN
IAG14168Medicare UPIN
IAI15593Medicare PIN