Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Y00000X | Otolaryngologist (ENT Doctor) | 11483 | SD |
N | 207Y00000X | Otolaryngologist (ENT Doctor) | 47540 | MN |
NPI | 1083680458 |
---|---|
Provider Name | Dr. Jonathan W Mellema |
First Address | Willmar, MN 56201-4946 |
Second Address | Willmar, MN 56201-4946 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/02/2006 |
Last Update Date | 22/06/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
312128300 | (05) | MN |
I32272 | (02) |