Healthcare Provider Details

I. General information

NPI: 1588635684
Provider Name (Legal Business Name): JONATHAN BRETT FUGITT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2006
Last Update Date: 12/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 MARSHALL WAY MARSHALL MEDICAL CENTER
PLACERVILLE CA
95667
US

IV. Provider business mailing address

681 MAIN STREET STE 105
PLACERVILLE CA
95667
US

V. Phone/Fax

Practice location:
  • Phone: 530-626-2774
  • Fax: 509-248-0178
Mailing address:
  • Phone: 530-626-1166
  • Fax: 530-626-3826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA85990
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberA85992
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License NumberA85990
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License NumberA85990
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD60491574
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: