Provider Demographics
NPI:1164685012
Name:FEDDOCK, JONATHAN MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:MICHAEL
Last Name:FEDDOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4560 WINDSTAR WAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515-4818
Mailing Address - Country:US
Mailing Address - Phone:859-229-2726
Mailing Address - Fax:
Practice Address - Street 1:800 ROSE STREET HQ-101
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-0293
Practice Address - Country:US
Practice Address - Phone:859-229-2726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-09
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR16692085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology