Provider Demographics
NPI:1053533919
Name:FONN, SONJAY JOSEPH (DO)
Entity type:Individual
Prefix:DR
First Name:SONJAY
Middle Name:JOSEPH
Last Name:FONN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:SANJAY
Other - Middle Name:JOSEPH
Other - Last Name:FONN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:65 DOCTORS PARK STE A
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-4927
Mailing Address - Country:US
Mailing Address - Phone:573-651-1687
Mailing Address - Fax:573-651-8734
Practice Address - Street 1:65 DOCTORS PARK STE A
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-4927
Practice Address - Country:US
Practice Address - Phone:573-651-1687
Practice Address - Fax:573-651-8734
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008003433207T00000X
OH58.001982390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
6202790001Medicare NSC