Provider Demographics
NPI:1639122708
Name:JONATHAN G WASH DPM PA
Entity type:Organization
Organization Name:JONATHAN G WASH DPM PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:GORDON
Authorized Official - Last Name:WASH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:254-741-1824
Mailing Address - Street 1:6609 SANGER AVE
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-4252
Mailing Address - Country:US
Mailing Address - Phone:254-741-1824
Mailing Address - Fax:254-741-1836
Practice Address - Street 1:6609 SANGER AVE
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-4252
Practice Address - Country:US
Practice Address - Phone:254-741-1824
Practice Address - Fax:254-741-1836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX178105601Medicaid
TX5664670001Medicare NSC
TXDE8753Medicare PIN
TX00999ZMedicare PIN