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General NPI Number Information
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NPI Number | 1356334049
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Entity Type | Individual
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Provider Name | JONATHAN EDWIN FOUNTAIN MD
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Gender | Male
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Dates
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Enumeration Date | 08/26/2005
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Last Update Date | 11/27/2015
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Provider Practice Location Address
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Address Line | 110 NE 5TH ST
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City | CARRABELLE
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State | FL
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Zip | 32322-3529
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Country | US
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Telephone | 850-653-8853
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Fax | 850-653-1897
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Provider Business Mailing Address
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Address Line | PO BOX 580
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City | APALACHICOLA
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State | FL
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Zip | 32329-0580
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Country | US
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Telephone | 850-653-8853
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Fax | 850-653-1897
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | ME0050330
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License Number State | FL
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