Provider Demographics
NPI:1154359339
Name:FONG, JONATHAN C (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:C
Last Name:FONG
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 863407
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-3407
Mailing Address - Country:US
Mailing Address - Phone:941-917-2600
Mailing Address - Fax:941-917-7884
Practice Address - Street 1:1540 S TAMIAMI TRL
Practice Address - Street 2:SUITE 303
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2930
Practice Address - Country:US
Practice Address - Phone:941-917-8791
Practice Address - Fax:941-917-8793
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME80268208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL49996BOtherBCBSFL HMO
FL49996OtherBCBS FL
FL49996AOtherBCBSFL HMO
FL258797100Medicaid
FL49996BOtherBCBSFL HMO
FL49996AOtherBCBSFL HMO
FL49996OtherBCBS FL
FL49996ZMedicare PIN
FLP00065544Medicare PIN
FL49996VMedicare PIN
FL49996YMedicare PIN
FL49996XMedicare PIN
FL49996WMedicare PIN