Healthcare Provider Details

I. General information

NPI: 1982994455
Provider Name (Legal Business Name): JONATHAN PATRICK STAIDLE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2011
Last Update Date: 01/19/2021
Certification Date: 01/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4814 SPARKS BLVD
SPARKS NV
89436-8219
US

IV. Provider business mailing address

640 W MOANA LN
RENO NV
89509-4903
US

V. Phone/Fax

Practice location:
  • Phone: 775-327-0699
  • Fax: 775-451-7501
Mailing address:
  • Phone: 775-324-0699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberMD457066
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number35-126612
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: