MEDICARE: DR. JONATHAN K STOUDMIRE MD

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	2084P0800X	Psychiatry Physician	200500827	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710959788
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN K STOUDMIRE MD

Provider Business Mailing Address
First Line	:	3046 SENNA DR
Second Line	:	SUITE B
City	:	MATTHEWS
State	:	NC
Zip	:	28105-6726
Country	:	US
Telephone Number	:	704-841-3886
Fax Number	:	704-841-3889

Provider Business Practice Location Address
First Line	:	3046 SENNA DR
Second Line	:	SUITE B
City	:	MATTHEWS
State	:	NC
Zip	:	28105-6726
Country	:	US
Telephone Number	:	704-841-3886
Fax Number	:	704-841-3889

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/03/2006
Last Update Date	:	07/11/2011

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