Provider Demographics
NPI:1174781686
Name:EKEDAHL, JONATHAN (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:EKEDAHL
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 1:1227 HAUBERT ST
Mailing Address - Street 2:OPHTH: OPHTHALMOLOGY
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230-5235
Mailing Address - Country:US
Mailing Address - Phone:301-520-6887
Mailing Address - Fax:
Practice Address - Street 1:100 PARK AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-3416
Practice Address - Country:US
Practice Address - Phone:410-752-1677
Practice Address - Fax:410-752-4435
Is Sole Proprietor?:No
Enumeration Date:2008-05-30
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0116021210390200000X
MDD74366207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program