Healthcare Provider Details

I. General information

NPI: 1639514722
Provider Name (Legal Business Name): JONATHAN EDWARD BJORK D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2013
Last Update Date: 04/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 HIGHLAND AVE
RANDOLPH VT
05060-1386
US

IV. Provider business mailing address

3 ELM ST
RANDOLPH VT
05060-1004
US

V. Phone/Fax

Practice location:
  • Phone: 608-256-1901
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number17859-875
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: