Provider Demographics
NPI:1982994455
Name:STAIDLE, JONATHAN PATRICK (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:PATRICK
Last Name:STAIDLE
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 1:640 W MOANA LN
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-4903
Mailing Address - Country:US
Mailing Address - Phone:775-324-0699
Mailing Address - Fax:
Practice Address - Street 1:4814 SPARKS BLVD
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89436-8219
Practice Address - Country:US
Practice Address - Phone:775-327-0699
Practice Address - Fax:775-451-7501
Is Sole Proprietor?:No
Enumeration Date:2011-04-18
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD457066207ND0101X
OH35-126612207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0129749Medicaid