Provider Demographics
NPI:1548826308
Name:BRUSHERD, JONATHAN DAVID (SOIDC)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DAVID
Last Name:BRUSHERD
Suffix:
Gender:M
Credentials:SOIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 SEA HUNTER WAY
Mailing Address - Street 2:
Mailing Address - City:SNEADS FERRY
Mailing Address - State:NC
Mailing Address - Zip Code:28460-6012
Mailing Address - Country:US
Mailing Address - Phone:479-644-7775
Mailing Address - Fax:
Practice Address - Street 1:710 SUMMIT LOOP
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-3040
Practice Address - Country:US
Practice Address - Phone:479-644-7775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-16
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman