Healthcare Provider Details

I. General information

NPI: 1033476304
Provider Name (Legal Business Name): JONATHAN DETOMMASO DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2012
Last Update Date: 11/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7601 W JEFFERSON BLVD
FORT WAYNE IN
46804-4133
US

IV. Provider business mailing address

PO BOX 2526
FORT WAYNE IN
46801-2526
US

V. Phone/Fax

Practice location:
  • Phone: 260-436-8686
  • Fax: 260-436-8585
Mailing address:
  • Phone: 866-401-3663
  • Fax: 260-407-4422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number07001204A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number07001204A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: