Provider Demographics
NPI:1902880420
Name:BARD, JONATHAN B (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:B
Last Name:BARD
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 1:7135 MIMOSA LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-5441
Mailing Address - Country:US
Mailing Address - Phone:214-378-8381
Mailing Address - Fax:214-853-5415
Practice Address - Street 1:710 HUNTERS ROW CT
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-4001
Practice Address - Country:US
Practice Address - Phone:817-453-7444
Practice Address - Fax:817-453-7441
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK79932085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G67695Medicare UPIN
83708RMedicare ID - Type Unspecified