Basic Information
Provider Information | |||||||||
NPI: | 1366507709 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROE | ||||||||
FirstName: | JONATHAN | ||||||||
MiddleName: | D | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3400 DEERFIELD DR | ||||||||
Address2: |   | ||||||||
City: | JANESVILLE | ||||||||
State: | WI | ||||||||
PostalCode: | 535463557 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6083143600 | ||||||||
FaxNumber: | 6083143601 | ||||||||
Practice Location | |||||||||
Address1: | 3400 DEERFIELD DR | ||||||||
Address2: |   | ||||||||
City: | JANESVILLE | ||||||||
State: | WI | ||||||||
PostalCode: | 535463557 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6083143600 | ||||||||
FaxNumber: | 6083143601 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/26/2006 | ||||||||
LastUpdateDate: | 04/16/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 35916-20 | WI | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 32061100 | 05 | WI |   | MEDICAID | 347845572 1 | 05 | IL |   | MEDICAID | ROEJON | 01 | WI | MERCYCARE INSURANCE | OTHER |