Healthcare Provider Details

I. General information

NPI: 1396706024
Provider Name (Legal Business Name): JONATHAN V. MAI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 03/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL PK. BLVD.
BRISTOL TN
37620
US

IV. Provider business mailing address

3053 W. STATE ST.
BRISTOL TN
37620
US

V. Phone/Fax

Practice location:
  • Phone: 423-968-1144
  • Fax: 423-968-3453
Mailing address:
  • Phone: 423-968-1144
  • Fax: 423-968-3453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD424783
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: