Healthcare Provider Details

I. General information

NPI: 1053534636
Provider Name (Legal Business Name): JONATHAN ZIZMOR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1017 3RD AVE SECOND FLOOR
NEW YORK NY
10021-8501
US

IV. Provider business mailing address

1017 3RD AVE SECOND FLOOR
NEW YORK NY
10021-8501
US

V. Phone/Fax

Practice location:
  • Phone: 212-688-8326
  • Fax: 212-688-8716
Mailing address:
  • Phone: 212-688-8326
  • Fax: 212-688-8716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number106081
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: