Provider Demographics
NPI:1013992783
Name:SULENTIC, JON E (DO)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:E
Last Name:SULENTIC
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 N BREIEL BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45042-3807
Mailing Address - Country:US
Mailing Address - Phone:513-424-7711
Mailing Address - Fax:513-424-3599
Practice Address - Street 1:275 N BREIEL BLVD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45042-3807
Practice Address - Country:US
Practice Address - Phone:513-424-7711
Practice Address - Fax:513-424-3599
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34008091207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2430711Medicaid
OH4120011Medicare PIN
OHH99512Medicare UPIN