Healthcare Provider Details

I. General information

NPI: 1205090974
Provider Name (Legal Business Name): JONATHAN WINSTON PHILLIPS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2008
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 CHESTNUT ST
NORWOOD NJ
07648-2001
US

IV. Provider business mailing address

7560 RED BUG LAKE RD
OVIEDO FL
32765-6591
US

V. Phone/Fax

Practice location:
  • Phone: 201-899-3560
  • Fax:
Mailing address:
  • Phone: 407-951-5833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberME110737
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number25MA10397400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: