Provider Demographics
NPI:1023286671
Name:JOSEPH J FONAGY JR DPM INC
Entity type:Organization
Organization Name:JOSEPH J FONAGY JR DPM INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:RENEE'
Authorized Official - Last Name:FONAGY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-369-1511
Mailing Address - Street 1:1507 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44483-6611
Mailing Address - Country:US
Mailing Address - Phone:330-369-1511
Mailing Address - Fax:330-369-3311
Practice Address - Street 1:1507 E MARKET ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483-6611
Practice Address - Country:US
Practice Address - Phone:330-369-1511
Practice Address - Fax:330-369-3311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-18
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003410213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2823181Medicaid
OH9373881Medicare PIN
OH5722650001Medicare NSC