Provider Demographics
NPI:1033476304
Name:DETOMMASO, JONATHAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:DETOMMASO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2526
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46801-2526
Mailing Address - Country:US
Mailing Address - Phone:866-401-3663
Mailing Address - Fax:260-407-4422
Practice Address - Street 1:7601 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4133
Practice Address - Country:US
Practice Address - Phone:260-436-8686
Practice Address - Fax:260-436-8585
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-11
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07001204A213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01524125OtherRAILROAD MEDICARE
IN201289140Medicaid
IN000000934131OtherANTHEM
IN000000934131OtherANTHEM