Healthcare Provider Details

I. General information

NPI: 1689644866
Provider Name (Legal Business Name): JONATHAN B. C. HUMPHREY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 02/07/2025
Certification Date: 02/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4165 BLACKHAWK PLAZA CIR #100
DANVILLE CA
94506-4904
US

IV. Provider business mailing address

4165 BLACKHAWK PLAZA CIR #100
DANVILLE CA
94506-4904
US

V. Phone/Fax

Practice location:
  • Phone: 925-736-7070
  • Fax: 925-736-7075
Mailing address:
  • Phone: 925-736-7070
  • Fax: 925-736-7075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG66292
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: