Provider Demographics
NPI:1386622819
Name:POWELL, JONATHAN D (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:D
Last Name:POWELL
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 1:1450 BUSCH PKWY STE 130
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-4541
Mailing Address - Country:US
Mailing Address - Phone:847-499-3070
Mailing Address - Fax:
Practice Address - Street 1:1051 W RAND RD STE 103
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60004-2315
Practice Address - Country:US
Practice Address - Phone:847-259-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036109242208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036109242Medicaid