Provider Demographics
NPI:1063623700
Name:EGLY, JONATHAN ANDREW (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:ANDREW
Last Name:EGLY
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 1:115 MEDICAL CIR STE 102
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751-9004
Mailing Address - Country:US
Mailing Address - Phone:036-765-5539
Mailing Address - Fax:
Practice Address - Street 1:115 MEDICAL CIR STE 102
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75751-9004
Practice Address - Country:US
Practice Address - Phone:036-765-5539
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP8240207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX330434YL21Medicare PIN