Provider Demographics
NPI:1083270003
Name:FUGATE, JONATHAN (OD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:FUGATE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 JOEL DR
Mailing Address - Street 2:
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223-5318
Mailing Address - Country:US
Mailing Address - Phone:417-872-7002
Mailing Address - Fax:
Practice Address - Street 1:576 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:FORT EUSTIS
Practice Address - State:VA
Practice Address - Zip Code:23604-1373
Practice Address - Country:US
Practice Address - Phone:417-872-7002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-15
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618002752152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist