Provider Demographics
NPI:1992467005
Name:EARLES, JONATHAN
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:EARLES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4309 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-2388
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4309 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2388
Practice Address - Country:US
Practice Address - Phone:919-385-7507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP19844208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation