Provider Demographics
NPI:1326254848
Name:KSOR, JONATHAN BRAUN (DPM)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:BRAUN
Last Name:KSOR
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 1:2502 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:SC
Mailing Address - Zip Code:29020-2238
Mailing Address - Country:US
Mailing Address - Phone:803-425-5510
Mailing Address - Fax:803-432-4776
Practice Address - Street 1:2502 BROAD ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:SC
Practice Address - Zip Code:29020-2238
Practice Address - Country:US
Practice Address - Phone:803-425-5510
Practice Address - Fax:803-432-4776
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3095213E00000X
SCPOD.614 POD213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPD6149Medicaid
FL65820Medicare ID - Type Unspecified
SCPD6149Medicaid
SC9465Medicare PIN
SCAA7174Medicare UPIN
FLU97512Medicare UPIN