Provider Demographics
NPI:1972801397
Name:EGBERT, JONATHAN BRAD (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:BRAD
Last Name:EGBERT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MR
Other - First Name:JONATHAN
Other - Middle Name:BRAD
Other - Last Name:EGBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:2570 NW EDENBOWER BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-6214
Mailing Address - Country:US
Mailing Address - Phone:541-677-7200
Mailing Address - Fax:541-229-3309
Practice Address - Street 1:2570 NW EDENBOWER BLVD STE 100
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-6214
Practice Address - Country:US
Practice Address - Phone:541-677-7200
Practice Address - Fax:541-229-3309
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-09
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA1449111N00000X
WY098-T2207Q00000X
ORMD193108207Q00000X, 207Q00000X
WY098-T1390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No111N00000XChiropractic ProvidersChiropractor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty