Provider Demographics
NPI:1780784629
Name:FORNCROOK, JONATHON A (DO)
Entity type:Individual
Prefix:
First Name:JONATHON
Middle Name:A
Last Name:FORNCROOK
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 1:1000 N OAK AVE
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-5702
Mailing Address - Country:US
Mailing Address - Phone:157-389-3141
Mailing Address - Fax:
Practice Address - Street 1:1000 N OAK AVE
Practice Address - Street 2:1F2
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449-6733
Practice Address - Country:US
Practice Address - Phone:715-389-3141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A 10861207R00000X, 208000000X
WI38920207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30093600Medicaid
WI30093600Medicaid
WI30093600Medicaid