Basic Information
| Provider Information | |||||||||
| NPI: | 1407913981 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JONATHAN E FOW MD INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 STATION WAY | ||||||||
| Address2: | SUITE C | ||||||||
| City: | ARROYO GRANDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934203348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054730700 | ||||||||
| FaxNumber: | 8054735931 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 STATION WAY | ||||||||
| Address2: | SUITE C | ||||||||
| City: | ARROYO GRANDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934203348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054730700 | ||||||||
| FaxNumber: | 8054735931 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2007 | ||||||||
| LastUpdateDate: | 02/11/2011 | ||||||||
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| AuthorizedOfficialLastName: | FOW | ||||||||
| AuthorizedOfficialFirstName: | JONATHAN | ||||||||
| AuthorizedOfficialMiddleName: | ELDREDGE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8054730700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 5816010001 | CA | N | Suppliers | Durable Medical Equipment & Medical Supplies | 207X00000X | A78523 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 7503617 | 01 | CA | AETNA PIN | OTHER | 00A785230 | 01 | CA | BLUE SHIELD PIN | OTHER | 00A785230 | 05 | CA | MEDICAID |