Healthcare Provider Details

I. General information

NPI: 1760939953
Provider Name (Legal Business Name): JONATHAN LORD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2016
Last Update Date: 09/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 LONG POINT DR
FERNANDINA BEACH FL
32034-6410
US

IV. Provider business mailing address

135 LONG POINT DR
FERNANDINA BEACH FL
32034-6410
US

V. Phone/Fax

Practice location:
  • Phone: 904-310-9511
  • Fax:
Mailing address:
  • Phone: 904-310-9511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZF0201X
TaxonomyForensic Pathology Physician
License Number36359
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number106931
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: