Healthcare Provider Details

I. General information

NPI: 1427678564
Provider Name (Legal Business Name): JONATHAN WILLNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2020
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 LAKEVILLE RD STE M50
NEW HYDE PARK NY
11042-1117
US

IV. Provider business mailing address

450 LAKEVILLE RD STE M50
NEW HYDE PARK NY
11042-1117
US

V. Phone/Fax

Practice location:
  • Phone: 800-472-5757
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number326627
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: