1396977385 NPI number — JONATHAN ROBERT FORQUER D.O.

Table of content: JONATHAN ROBERT FORQUER D.O. (NPI 1396977385)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396977385 NPI number — JONATHAN ROBERT FORQUER D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FORQUER
Provider First Name:
JONATHAN
Provider Middle Name:
ROBERT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396977385
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/05/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1153 E MAIN ST
Provider Second Line Business Mailing Address:
PO BOX 2563
Provider Business Mailing Address City Name:
LANCASTER
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43130-4056
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-687-8990
Provider Business Mailing Address Fax Number:
740-687-8230

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2405 N COLUMBUS ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
LANCASTER
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43130-8185
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-689-4480
Provider Business Practice Location Address Fax Number:
740-277-7692
Provider Enumeration Date:
08/10/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  34010160 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: 34-010160 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0065345 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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