Basic Information
| Provider Information | |||||||||
| NPI: | 1982826855 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | JONES | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 530 DEMOSS STREET | ||||||||
| Address2: | HIDALGO MEDICAL SERVICES | ||||||||
| City: | LORDSBURG | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880452618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755428384 | ||||||||
| FaxNumber: | 5755428367 | ||||||||
| Practice Location | |||||||||
| Address1: | 114 W. 11TH STREET | ||||||||
| Address2: | HMS MED SQUARE CLINIC | ||||||||
| City: | SILVER CITY | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880615136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753881511 | ||||||||
| FaxNumber: | 5755428367 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2007 | ||||||||
| LastUpdateDate: | 11/16/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 4615 | AZ | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | A-1692-12 | NM | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | NMA1029998 | 01 | NM | MEDICARE PTAN | OTHER | 53286758 | 05 | NM | MEDICAID |