Provider Demographics
NPI:1659391084
Name:FALLIS, JONATHON LEE (DPM)
Entity Type:Individual
Prefix:DR
First Name:JONATHON
Middle Name:LEE
Last Name:FALLIS
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 1:1513 UNION AVE
Mailing Address - Street 2:SUITE 1400
Mailing Address - City:MOBERLY
Mailing Address - State:MO
Mailing Address - Zip Code:65270
Mailing Address - Country:US
Mailing Address - Phone:660-263-6677
Mailing Address - Fax:660-263-6688
Practice Address - Street 1:1513 UNION AVE
Practice Address - Street 2:SUITE 1400
Practice Address - City:MOBERLY
Practice Address - State:MO
Practice Address - Zip Code:65270
Practice Address - Country:US
Practice Address - Phone:660-263-6677
Practice Address - Fax:660-263-6688
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002006341213E00000X
IL016004851213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00242773OtherRAILROAD MEDICARE
MO154392OtherBLUE CROSS/BLUE SHEILD
MO305751208Medicaid
MOP00241817OtherRAILROAD MEDICARE
MO5502300001OtherDMERC
MOP00242773OtherRAILROAD MEDICARE
IL061748265652701Medicaid
U67452Medicare UPIN
ILK30701Medicare PIN
IL061748265652701Medicaid