Provider Demographics
NPI:1396706024
Name:MAI, JONATHAN V (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:V
Last Name:MAI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3053 W. STATE ST.
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620
Mailing Address - Country:US
Mailing Address - Phone:423-968-1144
Mailing Address - Fax:423-968-3453
Practice Address - Street 1:1 MEDICAL PK. BLVD.
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620
Practice Address - Country:US
Practice Address - Phone:423-968-1144
Practice Address - Fax:423-968-3453
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4247832085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101401704Medicaid
PA101401704Medicaid
I38865Medicare UPIN