Healthcare Provider Details

I. General information

NPI: 1295228492
Provider Name (Legal Business Name): JONATHAN MARTIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2018
Last Update Date: 11/04/2022
Certification Date: 11/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 1ST AVE
NEW YORK NY
10029-7491
US

IV. Provider business mailing address

1901 1ST AVE
NEW YORK NY
10029-7491
US

V. Phone/Fax

Practice location:
  • Phone: 212-423-6271
  • Fax:
Mailing address:
  • Phone: 212-423-6271
  • 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 Code2084P0800X
TaxonomyPsychiatry Physician
License Number317393
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: