Provider Demographics
NPI:1730184912
Name:SKINNER, JONATHAN L (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:L
Last Name:SKINNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 PROFESSIONAL LN
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303-3875
Mailing Address - Country:US
Mailing Address - Phone:334-699-0060
Mailing Address - Fax:334-699-1018
Practice Address - Street 1:105 PROFESSIONAL LN
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-3875
Practice Address - Country:US
Practice Address - Phone:334-699-0060
Practice Address - Fax:334-699-0061
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL18574208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL135159Medicaid
AL000097074OtherAL BLUECROSS BLUESHIELD #
F92088Medicare UPIN
AL102I025130Medicare PIN