Provider Demographics
NPI:1225192487
Name:JONATHAN E FOW MD INC
Entity Type:Organization
Organization Name:JONATHAN E FOW MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:ELDREDGE
Authorized Official - Last Name:FOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-473-0700
Mailing Address - Street 1:200 STATION WAY
Mailing Address - Street 2:SUITE C
Mailing Address - City:ARROYO GRANDE
Mailing Address - State:CA
Mailing Address - Zip Code:93420-3348
Mailing Address - Country:US
Mailing Address - Phone:805-473-0700
Mailing Address - Fax:805-473-5931
Practice Address - Street 1:691 MORRO AVE
Practice Address - Street 2:
Practice Address - City:MORRO BAY
Practice Address - State:CA
Practice Address - Zip Code:93442-2233
Practice Address - Country:US
Practice Address - Phone:805-473-0700
Practice Address - Fax:805-473-5931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA78523207X00000X
CA5816010002332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A785230Medicaid
CA00A785230Medicaid
5816010002Medicare NSC