Provider Demographics
NPI:1215917430
Name:COOLIDGE, JONATHAN S (DO)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:S
Last Name:COOLIDGE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2756 MIRA VISTA LN
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75032-5476
Mailing Address - Country:US
Mailing Address - Phone:214-771-3162
Mailing Address - Fax:361-729-8854
Practice Address - Street 1:2756 MIRA VISTA LN
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-5476
Practice Address - Country:US
Practice Address - Phone:214-771-3162
Practice Address - Fax:361-729-8854
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2197207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH51893Medicare UPIN