Provider Demographics
NPI:1376787903
Name:PAXTON, JOHNATHAN A (IDMT)
Entity type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:A
Last Name:PAXTON
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2709 BISMARK ST
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-3820
Mailing Address - Country:US
Mailing Address - Phone:240-691-6687
Mailing Address - Fax:
Practice Address - Street 1:WEST PERIMETER RD BLDG 1050
Practice Address - Street 2:MALCOLM GROW MEDICAL CENTER
Practice Address - City:ANDREWS AFB
Practice Address - State:MD
Practice Address - Zip Code:20762
Practice Address - Country:US
Practice Address - Phone:240-857-8529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-27
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians