Provider Demographics
NPI:1912932450
Name:DEHART, JONATHAN R (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:R
Last Name:DEHART
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 1:111 17TH AVE E
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-5273
Mailing Address - Country:US
Mailing Address - Phone:320-762-1511
Mailing Address - Fax:320-762-6101
Practice Address - Street 1:111 17TH AVE E
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-5273
Practice Address - Country:US
Practice Address - Phone:320-762-1511
Practice Address - Fax:320-762-6101
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN49962207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHDE4196391Medicare ID - Type Unspecified
OH2692804Medicaid
I63942Medicare UPIN
MN328957000Medicaid