Healthcare Provider Details

I. General information

NPI: 1154374973
Provider Name (Legal Business Name): JONATHAN S MCGLOTHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 06/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 N WABASH AVE STE P2E
CHICAGO IL
60611-3591
US

IV. Provider business mailing address

15273 SLATEFORD RD
NOBLESVILLE IN
46062-7712
US

V. Phone/Fax

Practice location:
  • Phone: 312-955-0071
  • Fax:
Mailing address:
  • Phone: 317-267-9014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number35.124274
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number41406
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number4301111306
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number01043767A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: