Provider Demographics
NPI:1265612972
Name:UNDERWOOD, JONATHAN LANCE (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:LANCE
Last Name:UNDERWOOD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3207 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-1029
Mailing Address - Country:US
Mailing Address - Phone:229-242-8480
Mailing Address - Fax:229-241-0252
Practice Address - Street 1:3207 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-1029
Practice Address - Country:US
Practice Address - Phone:229-242-8480
Practice Address - Fax:229-241-0252
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-09
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA002394207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARES0000Medicare UPIN