MEDICARE: JON M NORTHAM, M.D.,P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician

General Provider Information

NPI Number	:	1083884787
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JON M NORTHAM, M.D.,P.A.

Provider Business Mailing Address
First Line	:	6 WOODMONT XING
Second Line	:
City	:	TEXARKANA
State	:	TX
Zip	:	75503-2100
Country	:	US
Telephone Number	:	903-791-1044
Fax Number	:	903-791-1047

Provider Business Practice Location Address
First Line	:	6 WOODMONT XING
Second Line	:
City	:	TEXARKANA
State	:	TX
Zip	:	75503-2100
Country	:	US
Telephone Number	:	903-791-1044
Fax Number	:	903-791-1047

Authorized Official
Title or Position	:	OWNER
Name	:	MR. JON MARK NORTHAM
Credential	:	M.D., P.A.
Telephone Number	:	903-791-1044

Provider Enumeration Date	:	03/10/2008
Last Update Date	:	06/24/2010

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