Provider Demographics
NPI:1265694673
Name:WIRJO, JONATHAN (DO)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:WIRJO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:660 S GREEN VALLEY PKWY STE 140
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-0431
Mailing Address - Country:US
Mailing Address - Phone:702-790-2701
Mailing Address - Fax:702-790-2706
Practice Address - Street 1:8950 W TROPICANA AVE STE 1
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89147-8138
Practice Address - Country:US
Practice Address - Phone:702-790-2701
Practice Address - Fax:702-790-2706
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVDO17162084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVGP172ZMedicare PIN