Healthcare Provider Details

I. General information

NPI: 1750919387
Provider Name (Legal Business Name): JONATHAN SUSSMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2020
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10220 ALLIANCE RD
BLUE ASH OH
45242-4710
US

IV. Provider business mailing address

10220 ALLIANCE RD
BLUE ASH OH
45242-4710
US

V. Phone/Fax

Practice location:
  • Phone: 513-841-7800
  • Fax:
Mailing address:
  • Phone: 513-841-7800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number35.155942
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: