1609190164 NPI number — JONATHAN E. FENTON D.O., P.C.

Table of content: (NPI 1609190164)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609190164 NPI number — JONATHAN E. FENTON D.O., P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JONATHAN E. FENTON D.O., P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1609190164
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/30/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
321 MAIN ST
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
WINOOSKI
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05404-1380
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-859-0000
Provider Business Mailing Address Fax Number:
802-859-0005

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
321 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
WINOOSKI
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05404-1380
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-859-0000
Provider Business Practice Location Address Fax Number:
802-859-0005
Provider Enumeration Date:
03/26/2010

Additional Information

Authorized Official

Authorized Official Last Name:
FENTON
Authorized Official First Name:
JONATHAN
Authorized Official Middle Name:
ERIC
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
802-859-0000

Provider Taxonomy Codes

  • Taxonomy code: 208VP0014X , with the licence number:  032-0000356 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 032-0000356 . This is a "STATE LICENSE" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".




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