Provider Demographics
NPI:1588635684
Name:FUGITT, JONATHAN BRETT (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:BRETT
Last Name:FUGITT
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 1:681 MAIN STREET
Mailing Address - Street 2:STE 105
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667
Mailing Address - Country:US
Mailing Address - Phone:530-626-1166
Mailing Address - Fax:530-626-3826
Practice Address - Street 1:1100 MARSHALL WAY
Practice Address - Street 2:MARSHALL MEDICAL CENTER
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667
Practice Address - Country:US
Practice Address - Phone:530-626-2774
Practice Address - Fax:509-248-0178
Is Sole Proprietor?:No
Enumeration Date:2006-01-28
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA859902085R0202X, 2085U0001X, 2085B0100X
CAA859922085N0700X
WAMD604915742085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0053460Medicaid
CAGR0053460Medicaid