Provider Demographics
NPI:1528113412
Name:FONDESSY, TERRENCE MERLE (MD)
Entity type:Individual
Prefix:
First Name:TERRENCE
Middle Name:MERLE
Last Name:FONDESSY
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 1:745 HASKINS RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-1637
Mailing Address - Country:US
Mailing Address - Phone:419-353-7069
Mailing Address - Fax:419-353-7076
Practice Address - Street 1:838 E WOOSTER ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-3186
Practice Address - Country:US
Practice Address - Phone:419-372-2271
Practice Address - Fax:419-354-3222
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-050793207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0616962Medicaid
OH0616962Medicaid
A15731Medicare UPIN
OHH077050Medicare PIN