Provider Demographics
NPI:1790101608
Name:DATTILO, JONATHAN ROSS (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ROSS
Last Name:DATTILO
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 1:8000 SR 64 E
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34212
Mailing Address - Country:US
Mailing Address - Phone:941-792-1404
Mailing Address - Fax:941-761-0712
Practice Address - Street 1:12416 66TH ST STE A
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33773-3430
Practice Address - Country:US
Practice Address - Phone:727-547-4700
Practice Address - Fax:727-394-8661
Is Sole Proprietor?:No
Enumeration Date:2014-03-16
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME144420207X00000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery