Provider Demographics
NPI:1962452904
Name:PASKO, JONATHAN EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:EDWARD
Last Name:PASKO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:730 N MACOMB ST
Mailing Address - Street 2:SUITE# 324
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-2900
Mailing Address - Country:US
Mailing Address - Phone:734-242-2440
Mailing Address - Fax:734-457-3622
Practice Address - Street 1:730 N MACOMB ST
Practice Address - Street 2:SUITE# 324
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-2900
Practice Address - Country:US
Practice Address - Phone:734-242-2440
Practice Address - Fax:734-457-3622
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301068355207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4632382Medicaid
MI0N96100Medicare ID - Type Unspecified
MI4632382Medicaid