Provider Demographics
NPI:1699792523
Name:FOW, JONATHAN E (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:E
Last Name:FOW
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 1:850 FAIR OAKS AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:ARROYO GRANDE
Mailing Address - State:CA
Mailing Address - Zip Code:93420-3929
Mailing Address - Country:US
Mailing Address - Phone:805-473-0700
Mailing Address - Fax:805-473-5931
Practice Address - Street 1:850 FAIR OAKS AVE STE 100
Practice Address - Street 2:
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420
Practice Address - Country:US
Practice Address - Phone:805-473-0700
Practice Address - Fax:805-473-5931
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA78523207XX0005X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A785230Medicaid
00A785230OtherBLUE SHIELD PIN
7503617OtherAETNA PIN
7503617OtherAETNA PIN
CA5816010001Medicare NSC
CAWA78523DMedicare PIN