Provider Demographics
NPI:1871916775
Name:OLDHAM, JONATHAN ANDREW (RD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ANDREW
Last Name:OLDHAM
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:JON
Other - Middle Name:ANDREW
Other - Last Name:OLDHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RD
Mailing Address - Street 1:G3317 BEECHER RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3615
Mailing Address - Country:US
Mailing Address - Phone:269-325-4115
Mailing Address - Fax:
Practice Address - Street 1:G3317 BEECHER RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3615
Practice Address - Country:US
Practice Address - Phone:269-325-4115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-28
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86000710133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered