Provider Demographics
NPI:1083884787
Name:JON M NORTHAM, M.D.,P.A.
Entity type:Organization
Organization Name:JON M NORTHAM, M.D.,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:NORTHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PA
Authorized Official - Phone:903-791-1044
Mailing Address - Street 1:6 WOODMONT XING
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-2100
Mailing Address - Country:US
Mailing Address - Phone:903-791-1044
Mailing Address - Fax:903-791-1047
Practice Address - Street 1:6 WOODMONT XING
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2100
Practice Address - Country:US
Practice Address - Phone:903-791-1044
Practice Address - Fax:903-791-1047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00960YMedicare PIN