Provider Demographics
NPI:1942246087
Name:FRATKIN, JONATHAN DAVID (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DAVID
Last Name:FRATKIN
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 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-1530
Mailing Address - Fax:601-984-1531
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:DEPT OF PATHOLOGY
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-1530
Practice Address - Fax:601-984-1531
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13061207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00110234Medicaid
AL156443Medicaid
MSP00648898OtherRR MEDICARE
MS220010996OtherRR MEDICARE
AL134522Medicaid
AL156443Medicaid
MS$$$$$$$$$OtherBCBS
AL134522Medicaid
AL156443Medicaid