Provider Demographics
NPI:1992702641
Name:BARHAM, JONATHAN MACK (M D)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:MACK
Last Name:BARHAM
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 1:3418 MEDICAL PARK DR
Mailing Address - Street 2:SUITE 5
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-2376
Mailing Address - Country:US
Mailing Address - Phone:318-388-8190
Mailing Address - Fax:318-329-5981
Practice Address - Street 1:3418 MEDICAL PARK DR
Practice Address - Street 2:SUITE 5
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-2376
Practice Address - Country:US
Practice Address - Phone:318-388-8190
Practice Address - Fax:318-329-5981
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07884R207V00000X
TXF0865207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1394831Medicaid
LA1394831Medicaid
LA5J979Medicare ID - Type Unspecified