Individual
DR. JONATHAN DETOMMASO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DPM
Contact information
Practice address
7601 W JEFFERSON BLVD, FORT WAYNE, IN 46804-4133
(260) 436-8686
(260) 436-8585
Mailing address
PO BOX 2526, FORT WAYNE, IN 46801-2526
(866) 401-3663
(260) 407-4422
Taxonomy
Speciality
Code
Description
License number
State
213E00000X
Podiatrist
07001204A
IN
213ES0103X
Foot & Ankle Surgery Podiatrist
Primary
07001204A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000934131
ANTHEM
IN
05
—
201289140
—
IN
01
—
P01524125
RAILROAD MEDICARE
IN
Enumeration date
04/11/2012
Last updated
11/07/2016
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