Healthcare Provider Details

I. General information

NPI: 1225192487
Provider Name (Legal Business Name): JONATHAN E FOW MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 02/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

691 MORRO AVE
MORRO BAY CA
93442-2233
US

IV. Provider business mailing address

200 STATION WAY SUITE C
ARROYO GRANDE CA
93420-3348
US

V. Phone/Fax

Practice location:
  • Phone: 805-473-0700
  • Fax: 805-473-5931
Mailing address:
  • Phone: 805-473-0700
  • Fax: 805-473-5931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberA78523
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number5816010002
License Number StateCA

VIII. Authorized Official

Name: JONATHAN ELDREDGE FOW
Title or Position: PRESIDENT
Credential: MD
Phone: 805-473-0700