Healthcare Provider Details

I. General information

NPI: 1093783367
Provider Name (Legal Business Name): JONATHAN DAVID KURT TRAGER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 12/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 MIDDLE NECK RD SUITE #5
GREAT NECK NY
11021-1126
US

IV. Provider business mailing address

32 BERKSHIRE RD
GREAT NECK NY
11023-2131
US

V. Phone/Fax

Practice location:
  • Phone: 516-482-5400
  • Fax: 516-482-5401
Mailing address:
  • Phone: 516-466-6649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number200519
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number200519
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number200519
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number200519-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: