Provider Demographics
NPI:1306809603
Name:SABOURIN, JONATHAN G (DPM)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:G
Last Name:SABOURIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 AQUIDNECK AVE STE 15
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02842-7280
Mailing Address - Country:US
Mailing Address - Phone:401-849-2157
Mailing Address - Fax:401-848-8441
Practice Address - Street 1:850 AQUIDNECK AVE STE 15
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:RI
Practice Address - Zip Code:02842-7280
Practice Address - Country:US
Practice Address - Phone:401-849-2157
Practice Address - Fax:401-848-8441
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDPM00316213ES0103X, 213E00000X
MA2210213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI212867OtherBLUE CROSS BLUE SHIELD
RI7056541Medicaid
RI411583OtherBLUE CHIP
RI007058216Medicare ID - Type Unspecified
RI0446510001Medicare NSC
V00286Medicare UPIN