Healthcare Provider Details

I. General information

NPI: 1568025401
Provider Name (Legal Business Name): JONATHAN RONSON KOPPEL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2019
Last Update Date: 04/22/2022
Certification Date: 04/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2109 BROADWAY
NEW YORK NY
10023-2138
US

IV. Provider business mailing address

710 PARK AVE APT 15A
NEW YORK NY
10021-4946
US

V. Phone/Fax

Practice location:
  • Phone: 212-523-8672
  • Fax: 212-492-5505
Mailing address:
  • Phone: 516-359-2008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number315668
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: