Healthcare Provider Details

I. General information

NPI: 1689960031
Provider Name (Legal Business Name): JONATHAN MARC LATZMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2011
Last Update Date: 05/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E 210TH ST DEPARTMENT OF RADIOLOGY
BRONX NY
10467-2401
US

IV. Provider business mailing address

1976 MARCUS AVENUE SUITE C101
NEW HYDE PARK NY
11042
US

V. Phone/Fax

Practice location:
  • Phone: 718-920-5506
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number288219-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: