Provider Demographics
NPI:1699941617
Name:FONDRAN, JOHN CHARLES (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:CHARLES
Last Name:FONDRAN
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 1:550 E MARKET ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44304-1613
Mailing Address - Country:US
Mailing Address - Phone:330-434-5978
Mailing Address - Fax:330-434-6908
Practice Address - Street 1:550 E MARKET ST
Practice Address - Street 2:SUITE 103
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44304-1613
Practice Address - Country:US
Practice Address - Phone:330-434-5978
Practice Address - Fax:330-434-6908
Is Sole Proprietor?:No
Enumeration Date:2008-04-30
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.090057208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2848744Medicaid
OH4239791OtherMEDICARE ID