Provider Demographics
NPI:1972573293
Name:DEWALD, JONATHON G (MD)
Entity type:Individual
Prefix:
First Name:JONATHON
Middle Name:G
Last Name:DEWALD
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:PO BOX 3585
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27895-3585
Mailing Address - Country:US
Mailing Address - Phone:252-243-7542
Mailing Address - Fax:
Practice Address - Street 1:2605 FOREST HILLS RD SW
Practice Address - Street 2:SUITE B
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-4448
Practice Address - Country:US
Practice Address - Phone:252-243-7542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28169207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC28378OtherBLUE CROSS/BLUE SHIELD
NC8928378Medicaid
NCC83523Medicare UPIN
NC28378OtherBLUE CROSS/BLUE SHIELD