Basic Information
| Provider Information | |||||||||
| NPI: | 1598342685 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOOTEE | ||||||||
| FirstName: | JONATHAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2622 W STONEHENGE CT | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616157477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3092297078 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265061200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045980430 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2021 | ||||||||
| LastUpdateDate: | 03/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.