=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467613216
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN JONISCH MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2008
-----------------------------------------------------
Last Update Date | 05/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 NORTHERN BLVD SUITE 216
-----------------------------------------------------
City | GREAT NECK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11021-5206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-594-1010
-----------------------------------------------------
Fax | 516-594-6058
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 600 NORTHERN BLVD STE 216
-----------------------------------------------------
City | GREAT NECK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11021-5200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-466-0390
-----------------------------------------------------
Fax | 516-466-4956
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 245936
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------