Healthcare Provider Details

I. General information

NPI: 1487566337
Provider Name (Legal Business Name): JONATHAN MARTIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 US HIGHWAY 46 STE 420
FAIRFIELD NJ
07004-1532
US

IV. Provider business mailing address

10 DAMSON LN
VALLEY STREAM NY
11581-1737
US

V. Phone/Fax

Practice location:
  • Phone: 701-433-0037
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: