Provider Demographics
NPI:1609190164
Name:JONATHAN E. FENTON D.O., P.C.
Entity Type:Organization
Organization Name:JONATHAN E. FENTON D.O., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:FENTON
Authorized Official - Suffix:
Authorized Official - Credentials:DO, PC
Authorized Official - Phone:802-859-0000
Mailing Address - Street 1:321 MAIN ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:WINOOSKI
Mailing Address - State:VT
Mailing Address - Zip Code:05404-1380
Mailing Address - Country:US
Mailing Address - Phone:802-859-0000
Mailing Address - Fax:802-859-0005
Practice Address - Street 1:321 MAIN ST
Practice Address - Street 2:SUITE C
Practice Address - City:WINOOSKI
Practice Address - State:VT
Practice Address - Zip Code:05404-1380
Practice Address - Country:US
Practice Address - Phone:802-859-0000
Practice Address - Fax:802-859-0005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-26
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT032-0000356208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT032-0000356OtherSTATE LICENSE
VT032-0000356OtherSTATE LICENSE