MEDICARE: DR. JONATHAN J KHODADADIAN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207UN0902X	Nuclear Imaging & Therapy Physician	265565	NY
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1275814618
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN J KHODADADIAN MD

Provider Business Mailing Address
First Line	:	150 E SUNRISE HWY
Second Line	:	208
City	:	LINDENHURST
State	:	NY
Zip	:	11757-2539
Country	:	US
Telephone Number	:	631-225-7200
Fax Number	:	631-930-9451

Provider Business Practice Location Address
First Line	:	150 E SUNRISE HWY
Second Line	:	208
City	:	LINDENHURST
State	:	NY
Zip	:	11757-2539
Country	:	US
Telephone Number	:	631-225-7200
Fax Number	:	631-930-9451

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2011
Last Update Date	:	07/11/2012

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