Healthcare Provider Details

I. General information

NPI: 1689688632
Provider Name (Legal Business Name): JONATHAN ERIC FENTON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 08/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 MAIN ST SUITE C
WINOOSKI VT
05404-1335
US

IV. Provider business mailing address

321 MAIN ST SUITE C
WINOOSKI VT
05404-1335
US

V. Phone/Fax

Practice location:
  • Phone: 802-859-0000
  • Fax: 802-859-0005
Mailing address:
  • Phone: 802-859-0000
  • Fax: 802-859-0005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number032-0000356
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number032-0000356
License Number StateVT
# 3
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number032-0000356
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: