Healthcare Provider Details

I. General information

NPI: 1629337928
Provider Name (Legal Business Name): JONATHAN MATTHEW GIFTOS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2012
Last Update Date: 08/13/2020
Certification Date: 08/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 E 3RD ST
NEW YORK NY
10003-8908
US

IV. Provider business mailing address

415 9TH ST APT 33
BROOKLYN NY
11215-4151
US

V. Phone/Fax

Practice location:
  • Phone: 212-533-8400
  • Fax: 212-529-4781
Mailing address:
  • Phone: 603-682-4543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number276899
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: