Provider Demographics
NPI:1649248204
Name:ORTMAN, JONATHAN A (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:A
Last Name:ORTMAN
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 1:403 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-3116
Mailing Address - Country:US
Mailing Address - Phone:815-285-5552
Mailing Address - Fax:815-285-5865
Practice Address - Street 1:403 E 1ST ST
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021
Practice Address - Country:US
Practice Address - Phone:815-285-5552
Practice Address - Fax:815-285-5865
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-077540207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL10167OtherMEDICARE PTAN
ILL53041OtherMEDICARE PTAN
IL036077540Medicaid
IL800200OtherMEDICARE GROUP PROVIDER NUMBER