Provider Demographics
NPI:1336179969
Name:SHOFFNER, JONATHAN DANIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:DANIEL
Last Name:SHOFFNER
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 1:1001 CRESCENT GRN
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27518-8101
Mailing Address - Country:US
Mailing Address - Phone:919-235-3042
Mailing Address - Fax:919-235-3094
Practice Address - Street 1:1001 CRESCENT GREEN
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511
Practice Address - Country:US
Practice Address - Phone:919-467-3211
Practice Address - Fax:919-467-5315
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200100462208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89128V6Medicaid
H32919Medicare UPIN