Provider Demographics
NPI:1154374973
Name:MCGLOTHAN, JONATHAN S (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:S
Last Name:MCGLOTHAN
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 1:15273 SLATEFORD RD
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46062-7712
Mailing Address - Country:US
Mailing Address - Phone:317-267-9014
Mailing Address - Fax:
Practice Address - Street 1:405 N WABASH AVE STE P2E
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3591
Practice Address - Country:US
Practice Address - Phone:312-955-0071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.124274207W00000X
KY41406207W00000X
MI4301111306207W00000X
IN01043767A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200039810CMedicaid
F84907Medicare UPIN
IN142730Medicare ID - Type Unspecified