Provider Demographics
NPI:1578592713
Name:FILLMORE, JONATHAN J (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:J
Last Name:FILLMORE
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 1:5520 PARK AVE
Mailing Address - Street 2:SUITE 306
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-3463
Mailing Address - Country:US
Mailing Address - Phone:203-373-7388
Mailing Address - Fax:203-373-7472
Practice Address - Street 1:5520 PARK AVE
Practice Address - Street 2:SUITE 306
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-3463
Practice Address - Country:US
Practice Address - Phone:203-373-7388
Practice Address - Fax:203-373-7472
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-01
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT039461207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT320051624OtherFEDERAL TAX ID (TIN)
CT320051624OtherFEDERAL TAX ID (TIN)
CTH69096Medicare UPIN
CT46000007929Medicare ID - Type UnspecifiedMEDICARE