Provider Demographics
NPI:1932173283
Name:JONATHAN T PAINE MD PA
Entity Type:Organization
Organization Name:JONATHAN T PAINE MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:PAINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-727-2468
Mailing Address - Street 1:1305 VALENTINE ST
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3127
Mailing Address - Country:US
Mailing Address - Phone:321-727-2468
Mailing Address - Fax:321-952-0163
Practice Address - Street 1:1305 VALENTINE ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3127
Practice Address - Country:US
Practice Address - Phone:321-727-2468
Practice Address - Fax:321-952-0163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-14
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0050830207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0470639OtherAETNA HMO
FL046080000Medicaid
FL03944OtherBLUE CROSS BLUE SHIELD
FL4039014OtherAETNA PPO
FL6656062002OtherCIGNA
FL140001058OtherRAILROAD MEDICARE
FL6656062002OtherCIGNA
FLK1370Medicare PIN