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General NPI Number Information
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NPI Number | 1891792255
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Entity Type | Individual
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Provider Name | JONATHAN GUSDORFF D.O.
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Gender | Male
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Dates
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Enumeration Date | 06/30/2005
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Last Update Date | 11/21/2019
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Provider Practice Location Address
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Address Line | 1305 W CHESTER PIKE
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City | HAVERTOWN
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State | PA
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Zip | 19083-2929
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Country | US
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Telephone | 610-482-4949
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Fax | 610-482-4950
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Provider Business Mailing Address
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Address Line | 1305 W CHESTER PIKE
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City | HAVERTOWN
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State | PA
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Zip | 19083-2929
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Country | US
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Telephone | 610-482-4949
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Fax | 610-482-4950
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085N0700X
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Taxonomy Name | Neuroradiology Physician
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License Number | 02005865A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 4519
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License Number State | OK
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Taxonomy #3
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | OS010370L
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License Number State | PA
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Taxonomy #4
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | OS010370L
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License Number State | PA
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