Healthcare Provider Details

I. General information

NPI: 1952549644
Provider Name (Legal Business Name): JONATHAN MARSHALL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2009
Last Update Date: 06/04/2025
Certification Date: 06/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

462 GRIDER ST
BUFFALO NY
14215-3021
US

IV. Provider business mailing address

908 NIAGARA FALLS BLVD STE 208
NORTH TONAWANDA NY
14120-2019
US

V. Phone/Fax

Practice location:
  • Phone: 716-898-3000
  • Fax:
Mailing address:
  • Phone: 716-692-2160
  • Fax: 716-213-0935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberOS20405
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number21991
License Number StateND
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number270540
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: