Provider Demographics
NPI:1992970115
Name:MAYNARD, JONATHAN RAY (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:RAY
Last Name:MAYNARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JONATHAN
Other - Middle Name:RAY
Other - Last Name:MAYNARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1595
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-1595
Mailing Address - Country:US
Mailing Address - Phone:606-408-6200
Mailing Address - Fax:606-408-6612
Practice Address - Street 1:2301 LEXINGTON AVE STE 135
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-2800
Practice Address - Country:US
Practice Address - Phone:606-408-8400
Practice Address - Fax:606-408-6770
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTP960208000000X
KY44675208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100173180Medicaid
OH0050712Medicaid
WV3810021011Medicaid
OH0050712Medicaid