Provider Demographics
NPI:1740280072
Name:SHUMATE, JONATHAN KALE GAVIN (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:KALE GAVIN
Last Name:SHUMATE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JONATHAN KALE
Other - Middle Name:GAVIN
Other - Last Name:SHUMATE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1010 SW COAST HWY STE 102
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365-5239
Mailing Address - Country:US
Mailing Address - Phone:541-265-4253
Mailing Address - Fax:541-265-4035
Practice Address - Street 1:1010 SW COAST HWY STE 102
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-5239
Practice Address - Country:US
Practice Address - Phone:541-265-4253
Practice Address - Fax:541-265-4035
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.200122207V00000X
WAMD00047503207V00000X
ORMD154161207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500635045Medicaid