Provider Demographics
NPI:1689688632
Name:FENTON, JONATHAN ERIC (DO)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:ERIC
Last Name:FENTON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
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:05404-1335
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:05404-1335
Practice Address - Country:US
Practice Address - Phone:802-859-0000
Practice Address - Fax:802-859-0005
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VT032-0000356204D00000X, 2081P2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F23588Medicare UPIN