Provider Demographics
NPI:1134449374
Name:NATHAN, JONATHAN (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:NATHAN
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 1:6565 HILLCREST AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75205-1840
Mailing Address - Country:US
Mailing Address - Phone:972-512-4800
Mailing Address - Fax:214-484-9994
Practice Address - Street 1:6565 HILLCREST AVE STE 110
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75205-1840
Practice Address - Country:US
Practice Address - Phone:972-512-4800
Practice Address - Fax:214-484-9994
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-10
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT0295208200000X
IL036.138399208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery