Provider Demographics
NPI:1821058579
Name:FONAGY, JOSEPH JOHN JR (DPM)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:JOHN
Last Name:FONAGY
Suffix:JR
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 1:1507 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44483-6611
Mailing Address - Country:US
Mailing Address - Phone:330-369-1511
Mailing Address - Fax:
Practice Address - Street 1:1507 E MARKET ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483-6611
Practice Address - Country:US
Practice Address - Phone:330-369-1511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-26
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3410213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2823181Medicaid
V08930Medicare UPIN
OH5722650001Medicare NSC
OH4180471Medicare PIN