Provider Demographics
NPI:1427106749
Name:DUNHAM, JON (HT)
Entity type:Individual
Prefix:MR
First Name:JON
Middle Name:
Last Name:DUNHAM
Suffix:
Gender:M
Credentials:HT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11175 MOUNTAIN VIEW AVE
Mailing Address - Street 2:SUITE K
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3865
Mailing Address - Country:US
Mailing Address - Phone:909-796-0113
Mailing Address - Fax:
Practice Address - Street 1:11175 MOUNTAIN VIEW AVE
Practice Address - Street 2:SUITE K
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3865
Practice Address - Country:US
Practice Address - Phone:909-796-0113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA246QH0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QH0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyHistology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMMM00317MMedicare ID - Type Unspecified