Healthcare Provider Details

I. General information

NPI: 1306041728
Provider Name (Legal Business Name): JONATHAN E. BANKOFF MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2007
Last Update Date: 11/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 CRESCENT ST
MIDDLETOWN CT
06457-3654
US

IV. Provider business mailing address

28 CRESCENT ST
MIDDLETOWN CT
06457-3654
US

V. Phone/Fax

Practice location:
  • Phone: 860-358-6394
  • Fax: 860-344-6748
Mailing address:
  • Phone: 860-358-6394
  • Fax: 860-344-6748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number045489
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: