Provider Demographics
NPI:1013999598
Name:PINE, JONATHAN B (DO)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:B
Last Name:PINE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 W PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:ANACONDA
Mailing Address - State:MT
Mailing Address - Zip Code:59711-1931
Mailing Address - Country:US
Mailing Address - Phone:406-563-8500
Mailing Address - Fax:406-563-8694
Practice Address - Street 1:305 W PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:ANACONDA
Practice Address - State:MT
Practice Address - Zip Code:59711
Practice Address - Country:US
Practice Address - Phone:406-563-8571
Practice Address - Fax:406-563-8523
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB05029700207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1013999598Medicaid
E69532Medicare UPIN
NJP1647069Medicaid