Healthcare Provider Details

I. General information

NPI: 1093334021
Provider Name (Legal Business Name): JACOB FONDRIEST MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2020
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

262 NEIL AVE STE 420
COLUMBUS OH
43215-7312
US

IV. Provider business mailing address

262 NEIL AVE STE 430
COLUMBUS OH
43215-7312
US

V. Phone/Fax

Practice location:
  • Phone: 614-224-4297
  • Fax: 614-224-5668
Mailing address:
  • Phone: 614-221-7464
  • Fax: 614-999-9235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0120X
TaxonomyCornea and External Diseases Specialist Physician
License Number35.152428
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number35.152428
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: