Basic Information
| Provider Information | |||||||||
| NPI: | 1265712160 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRISSON | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2147 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339022147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393437100 | ||||||||
| FaxNumber: | 2393437190 | ||||||||
| Practice Location | |||||||||
| Address1: | 12645 NEW BRITTANY BLVD BLDG 15 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339073631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392913600 | ||||||||
| FaxNumber: | 2392913601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2011 | ||||||||
| LastUpdateDate: | 12/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | OS12070 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 013040700 | 05 | FL | MEDICAID |