Provider Demographics
NPI:1356334049
Name:FOUNTAIN, JONATHAN EDWIN (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:EDWIN
Last Name:FOUNTAIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 580
Mailing Address - Street 2:
Mailing Address - City:APALACHICOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32329-0580
Mailing Address - Country:US
Mailing Address - Phone:850-653-8853
Mailing Address - Fax:850-653-1897
Practice Address - Street 1:110 NE 5TH ST
Practice Address - Street 2:
Practice Address - City:CARRABELLE
Practice Address - State:FL
Practice Address - Zip Code:32322-3529
Practice Address - Country:US
Practice Address - Phone:850-653-8853
Practice Address - Fax:850-653-1897
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2015-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0050330207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015154400Medicaid
FL015159600Medicaid
FL015159600Medicaid