Provider Demographics
NPI:1962492074
Name:SQUIRES, JONATHAN C (M D)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:C
Last Name:SQUIRES
Suffix:
Gender:M
Credentials:M D
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 660
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33757-0660
Mailing Address - Country:US
Mailing Address - Phone:727-793-9300
Mailing Address - Fax:727-793-0052
Practice Address - Street 1:1106 DRUID RD S
Practice Address - Street 2:SUITE 302
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-3846
Practice Address - Country:US
Practice Address - Phone:727-441-3711
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS74592085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL44977OtherBCBS
FL44977Medicare ID - Type UnspecifiedMEDICARE NUMBER
FL44977OtherBCBS