Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207N00000X | Dermatologist | 5101021659 | MI |
Y | 207ND0101X | MOHS-Micrographic Surgeon | 5101021659 | MI |
NPI | 1225411705 |
---|---|
Provider Name | Dr. Ryan Timothy Jones |
First Address | Portage, MI 49024-4883 |
Second Address | Portage, MI 49024-4883 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/07/2015 |
Last Update Date | 16/09/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1225411705 | (05) | MI |