Provider Demographics
NPI:1770283590
Name:DESIMONE, JONATHAN HENRY
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:HENRY
Last Name:DESIMONE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 HAYES AVENUE
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-3323
Mailing Address - Country:US
Mailing Address - Phone:419-557-7455
Mailing Address - Fax:419-557-7782
Practice Address - Street 1:1111 HAYES AVE
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-3323
Practice Address - Country:US
Practice Address - Phone:419-557-7455
Practice Address - Fax:419-557-7782
Is Sole Proprietor?:No
Enumeration Date:2023-03-09
Last Update Date:2025-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.017401208D00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0019519Medicaid