Provider Demographics
NPI:1336396910
Name:MELQUIST, JONATHAN JAY (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:JAY
Last Name:MELQUIST
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:PO BOX 45278
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32232-5278
Mailing Address - Country:US
Mailing Address - Phone:904-202-2092
Mailing Address - Fax:904-393-7603
Practice Address - Street 1:1301 PALM AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8432
Practice Address - Country:US
Practice Address - Phone:904-202-7300
Practice Address - Fax:904-202-7433
Is Sole Proprietor?:No
Enumeration Date:2008-08-26
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXP6036208800000X
FLME123683208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX335734501 (MDACC)Medicaid
TX349848YKQH (MDACC)Medicare PIN