Provider Demographics
NPI:1790837615
Name:FAIN, JONATHAN SIMON (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:SIMON
Last Name:FAIN
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 1:5700 SOUTHWYCK BLVD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-1509
Mailing Address - Country:US
Mailing Address - Phone:800-288-8325
Mailing Address - Fax:419-866-5453
Practice Address - Street 1:335 GLESSNER AVE
Practice Address - Street 2:PATHOLOGY DEPARTMENT
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-2269
Practice Address - Country:US
Practice Address - Phone:419-526-8509
Practice Address - Fax:419-520-2846
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35063392207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0881149Medicaid
OHFA0827022Medicare ID - Type Unspecified
OH0881149Medicaid