Provider Demographics
NPI:1205090974
Name:PHILLIPS, JONATHAN WINSTON (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:WINSTON
Last Name:PHILLIPS
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 1:7560 RED BUG LAKE RD
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-6591
Mailing Address - Country:US
Mailing Address - Phone:407-951-5833
Mailing Address - Fax:
Practice Address - Street 1:335 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:NORWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07648-2001
Practice Address - Country:US
Practice Address - Phone:201-899-3560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-11
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME110737207QS0010X
NJ25MA10397400207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLGC898ZMedicare PIN