Provider Demographics
NPI:1275500811
Name:FONTENOT, JONATHAN W (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:W
Last Name:FONTENOT
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 1:323 E HAWKINS PKWY STE A
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-8162
Mailing Address - Country:US
Mailing Address - Phone:903-758-2746
Mailing Address - Fax:903-758-7127
Practice Address - Street 1:323 E HAWKINS PKWY STE A
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-8162
Practice Address - Country:US
Practice Address - Phone:903-758-2746
Practice Address - Fax:903-758-7127
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9533207XX0005X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX141243905Medicaid
TXP00185770OtherRR MEDICARE
TX141243903Medicaid
TXP00185770OtherRR MEDICARE