Provider Demographics
NPI:1093334021
Name:FONDRIEST, JACOB (MD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:FONDRIEST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:7101 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418-3701
Mailing Address - Country:US
Mailing Address - Phone:305-243-2020
Mailing Address - Fax:561-355-8600
Practice Address - Street 1:7101 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33418-3701
Practice Address - Country:US
Practice Address - Phone:305-243-2020
Practice Address - Fax:561-355-8600
Is Sole Proprietor?:No
Enumeration Date:2020-04-09
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME167350207W00000X, 207WX0120X
IL125.077345207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0120XAllopathic & Osteopathic PhysiciansOphthalmologyCornea and External Diseases Specialist
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology