Provider Demographics
NPI:1093334021
Name:FONDRIEST, JACOB (MD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:FONDRIEST
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 1:262 NEIL AVE STE 420
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-7312
Mailing Address - Country:US
Mailing Address - Phone:614-224-4297
Mailing Address - Fax:614-224-5668
Practice Address - Street 1:262 NEIL AVE STE 420
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-7312
Practice Address - Country:US
Practice Address - Phone:614-224-4297
Practice Address - Fax:614-224-5668
Is Sole Proprietor?:No
Enumeration Date:2020-04-09
Last Update Date:2025-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME167350207W00000X
OH35.152428207WX0120X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0120XAllopathic & Osteopathic PhysiciansOphthalmologyCornea and External Diseases Specialist