Provider Demographics
NPI:1720059108
Name:BLEDSOE, JONATHAN M (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:M
Last Name:BLEDSOE
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:PO BOX 1510
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54702-1510
Mailing Address - Country:US
Mailing Address - Phone:715-838-5222
Mailing Address - Fax:
Practice Address - Street 1:1221 WHIPPLE ST
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54703
Practice Address - Country:US
Practice Address - Phone:715-838-5222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN46666207T00000X
NV13456207T00000X
WI56009207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN650967300Medicaid
WI1720059108Medicaid
MN140000282Medicare ID - Type Unspecified
MN650967300Medicaid
WI1720059108Medicaid
I12107Medicare UPIN