Provider Demographics
NPI:1912402744
Name:THERIOT, JONATHAN (DO)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:THERIOT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 MILL ST # M14
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-1576
Mailing Address - Country:US
Mailing Address - Phone:775-982-5262
Mailing Address - Fax:775-982-2834
Practice Address - Street 1:10315 PROFESSIONAL CIR STE 101
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89521-4803
Practice Address - Country:US
Practice Address - Phone:775-982-2828
Practice Address - Fax:775-982-2834
Is Sole Proprietor?:No
Enumeration Date:2018-03-25
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVDO3118207R00000X
AZ008400208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice