MEDICARE: MR. JONATHAN LOUIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	003291819A	GA

General Provider Information

NPI Number	:	1801751383
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JONATHAN LOUIS

Provider Business Mailing Address
First Line	:	1745 PHOENIX BLVD STE 300-335
Second Line	:
City	:	COLLEGE PARK
State	:	GA
Zip	:	30349-5591
Country	:	US
Telephone Number	:	929-884-5613
Fax Number	:	347-577-9445

Provider Business Practice Location Address
First Line	:	1745 PHOENIX BLVD STE 300-335
Second Line	:
City	:	COLLEGE PARK
State	:	GA
Zip	:	30349-5591
Country	:	US
Telephone Number	:	929-884-5613
Fax Number	:	347-577-9445

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/17/2025
Last Update Date	:	12/17/2025

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Directions to “ MR. JONATHAN LOUIS ” Practice Location

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