Provider Demographics
NPI:1801070370
Name:IDA, JONATHAN BENJAMIN (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:BENJAMIN
Last Name:IDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:225 E CHICAGO AVE # 25
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2991
Mailing Address - Country:US
Mailing Address - Phone:312-227-6234
Mailing Address - Fax:312-227-9414
Practice Address - Street 1:225 E CHICAGO AVE # 25
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2991
Practice Address - Country:US
Practice Address - Phone:312-227-6234
Practice Address - Fax:312-227-9414
Is Sole Proprietor?:No
Enumeration Date:2007-12-19
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.200263207Y00000X
OH35.094270207YP0228X
IL1801070370207YP0228X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric Otolaryngology
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology