Provider Demographics
NPI:1841273521
Name:SOMMERVILLE, JONATHAN W (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:W
Last Name:SOMMERVILLE
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:P.O. BOX 420
Mailing Address - Street 2:
Mailing Address - City:HAVRE DE GRACE
Mailing Address - State:MD
Mailing Address - Zip Code:21078
Mailing Address - Country:US
Mailing Address - Phone:410-939-3121
Mailing Address - Fax:410-939-8278
Practice Address - Street 1:308 N. UNION AVENUE
Practice Address - Street 2:
Practice Address - City:HAVRE DE GRACE
Practice Address - State:MD
Practice Address - Zip Code:21078
Practice Address - Country:US
Practice Address - Phone:410-939-3121
Practice Address - Fax:410-939-8278
Is Sole Proprietor?:No
Enumeration Date:2005-11-27
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0061484207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG03980Medicare UPIN