Provider Demographics
NPI:1821074295
Name:BINGHAM, JONATHAN L (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:L
Last Name:BINGHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:7300 RANCH ROAD 2222 STE 200
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78730-3204
Mailing Address - Country:US
Mailing Address - Phone:512-628-0465
Mailing Address - Fax:512-233-2711
Practice Address - Street 1:100 PARK DR S
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59401-3637
Practice Address - Country:US
Practice Address - Phone:406-613-7160
Practice Address - Fax:406-831-5345
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MT21190207ND0101X
CO46330207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1821074295Medicaid
MTM011003207Medicare PIN