MEDICARE: MR. JONATHAN TAD FOGEL M.D.

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	2085R0204X	Vascular & Interventional Radiology Physician	248396	NY
2	207P00000X	Emergency Medicine Physician	248396	NY

General Provider Information

NPI Number	:	1881692648
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JONATHAN TAD FOGEL M.D.

Provider Business Mailing Address
First Line	:	1345 RXR PLZ FL 13
Second Line	:
City	:	UNIONDALE
State	:	NY
Zip	:	11556-1301
Country	:	US
Telephone Number	:	516-453-0435
Fax Number	:	646-846-3283

Provider Business Practice Location Address
First Line	:	1470 METROPOLITAN AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10462-7446
Country	:	US
Telephone Number	:	718-571-9270
Fax Number	:	716-859-7388

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

Provider Enumeration Date	:	07/14/2005
Last Update Date	:	10/23/2018

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