Provider Demographics
NPI:1336720069
Name:HOSTY, JONATHON CLARK (MD)
Entity type:Individual
Prefix:
First Name:JONATHON
Middle Name:CLARK
Last Name:HOSTY
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5550 S EAST ST STE 1
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-1979
Practice Address - Country:US
Practice Address - Phone:317-780-4080
Practice Address - Fax:317-780-4088
Is Sole Proprietor?:No
Enumeration Date:2021-04-15
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01094065A207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1104205850OtherANTHEM PTAN
IN300051422Medicaid
IN068010A05OtherMEDICARE PTAN