Provider Demographics
NPI:1922195627
Name:KETCHUM, JONATHAN F (DPM)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:F
Last Name:KETCHUM
Suffix:
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 1:126 BUSHY LN
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01543-2025
Mailing Address - Country:US
Mailing Address - Phone:508-886-6280
Mailing Address - Fax:
Practice Address - Street 1:488 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01609-1857
Practice Address - Country:US
Practice Address - Phone:508-755-9573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2087213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY71045OtherBLUE SHIELD OF MA
MA333402OtherHARVARD PILGRIM HEALTH
MA0019046OtherNEIGHBORHOOD HEALTH
MA002087OtherTUFTS HEALTH PLAN
MA0316644Medicaid
MA2700355OtherUNITED HEALTHCARE
MA0316644Medicaid
MA2700355OtherUNITED HEALTHCARE