Provider Demographics
NPI:1053657643
Name:DEGORTER, JONATHAN SHEA (DC)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:SHEA
Last Name:DEGORTER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 COLD SPRING RD STE 102A
Mailing Address - Street 2:
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-3140
Mailing Address - Country:US
Mailing Address - Phone:516-921-1295
Mailing Address - Fax:516-496-2860
Practice Address - Street 1:99 COLD SPRING RD STE 102A
Practice Address - Street 2:
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-3140
Practice Address - Country:US
Practice Address - Phone:516-921-1295
Practice Address - Fax:516-496-2860
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-31
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX012214-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor