Provider Demographics
NPI:1750417309
Name:JONATHAN S. MCGLOTHAN
Entity type:Organization
Organization Name:JONATHAN S. MCGLOTHAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGLOTHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-467-2392
Mailing Address - Street 1:PO BOX 1165
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47706-1165
Mailing Address - Country:US
Mailing Address - Phone:812-471-1591
Mailing Address - Fax:812-471-6650
Practice Address - Street 1:3498 S 4TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-4168
Practice Address - Country:US
Practice Address - Phone:877-499-3937
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200039810Medicaid
IN200039810Medicaid