Provider Demographics
NPI:1912432386
Name:DVORAK, JONATHAN
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:DVORAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1523 ELIZABETH AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-2794
Mailing Address - Country:US
Mailing Address - Phone:704-910-1402
Mailing Address - Fax:704-910-1402
Practice Address - Street 1:1523 ELIZABETH AVE STE 200
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2794
Practice Address - Country:US
Practice Address - Phone:704-910-1402
Practice Address - Fax:704-910-1402
Is Sole Proprietor?:No
Enumeration Date:2017-04-24
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2021-00162208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice