Provider Demographics
NPI:1013062660
Name:BOURNE, JONATHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:BOURNE
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:PO BOX 660
Mailing Address - Street 2:85 SIERRA PARK RD
Mailing Address - City:MAMMOTH LAKES
Mailing Address - State:CA
Mailing Address - Zip Code:93546-0660
Mailing Address - Country:US
Mailing Address - Phone:760-924-4078
Mailing Address - Fax:760-924-4058
Practice Address - Street 1:85 SIERRA PARK RD
Practice Address - Street 2:
Practice Address - City:MAMMOTH LAKES
Practice Address - State:CA
Practice Address - Zip Code:93546-0660
Practice Address - Country:US
Practice Address - Phone:760-924-4078
Practice Address - Fax:760-924-4058
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG48548207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology