Healthcare Provider Details

I. General information

NPI: 1043215841
Provider Name (Legal Business Name): JONATHAN R MOLDOVER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 12/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 DWIGHT ROAD STE 104
LONGMEADOW MA
01106
US

IV. Provider business mailing address

280 CHESTNUT ST 2ND FLOOR
SPRINGFIELD MA
01199-1001
US

V. Phone/Fax

Practice location:
  • Phone: 413-794-5600
  • Fax: 413-794-2733
Mailing address:
  • Phone: 413-794-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number262755
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number262755
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: