Healthcare Provider Details

I. General information

NPI: 1992970115
Provider Name (Legal Business Name): JONATHAN RAY MAYNARD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JONATHAN RAY MAYNARD MD

II. Dates (important events)

Enumeration Date: 04/29/2008
Last Update Date: 12/01/2021
Certification Date: 12/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 LEXINGTON AVE STE 135
ASHLAND KY
41101-2800
US

IV. Provider business mailing address

PO BOX 1595
ASHLAND KY
41105-1595
US

V. Phone/Fax

Practice location:
  • Phone: 606-408-8400
  • Fax: 606-408-6770
Mailing address:
  • Phone: 606-408-6200
  • Fax: 606-408-6612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberTP960
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number44675
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: