Healthcare Provider Details

I. General information

NPI: 1083939839
Provider Name (Legal Business Name): JONATHAN S RUAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2010
Last Update Date: 11/15/2022
Certification Date: 11/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5645 MAIN ST
FLUSHING NY
11355-5045
US

IV. Provider business mailing address

5645 MAIN ST
FLUSHING NY
11355-5045
US

V. Phone/Fax

Practice location:
  • Phone: 718-670-2000
  • Fax:
Mailing address:
  • Phone: 718-670-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number263616
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: