Healthcare Provider Details

I. General information

NPI: 1265536635
Provider Name (Legal Business Name): JONATHAN JAY BEITLER MD, MBA, FACR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 11/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1365 CLIFTON RD NE DEPARTMENT OF RADIATION ONCOLOGY
ATLANTA GA
30322-1013
US

IV. Provider business mailing address

1 OGDEN RD
NEW CANAAN CT
06840-2210
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-5525
  • Fax:
Mailing address:
  • Phone: 203-972-0160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number154501
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number043800
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberG63032
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number154501
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number043800
License Number StateCT
# 6
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number60043
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: