Provider Demographics
NPI:1023447737
Name:POWELL, JONATHAN LARMOUR (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:LARMOUR
Last Name:POWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1921
Mailing Address - Street 2:
Mailing Address - City:CHINLE
Mailing Address - State:AZ
Mailing Address - Zip Code:86503-1921
Mailing Address - Country:US
Mailing Address - Phone:917-504-6337
Mailing Address - Fax:
Practice Address - Street 1:HIGHWAY 191
Practice Address - Street 2:CHINLE HOSPITAL
Practice Address - City:CHINLE
Practice Address - State:AZ
Practice Address - Zip Code:86503-1921
Practice Address - Country:US
Practice Address - Phone:917-504-6337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-03
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA132545207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ170247Medicaid