Healthcare Provider Details

I. General information

NPI: 1457339301
Provider Name (Legal Business Name): JOHNATHAN MARK COMPTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/01/2006
Last Update Date: 09/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1599 J ST
GRAND FORKS AFB ND
58205-6306
US

IV. Provider business mailing address

1599 J ST
GRAND FORKS AFB ND
58205-6306
US

V. Phone/Fax

Practice location:
  • Phone: 701-747-5391
  • Fax:
Mailing address:
  • Phone: 701-747-5391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM7916
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2003024388
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number04-34105
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: