Provider Demographics
NPI:1073616199
Name:KOBLENZER, JONATHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:KOBLENZER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 E 79TH ST
Mailing Address - Street 2:SUITE 42
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-0150
Mailing Address - Country:US
Mailing Address - Phone:212-794-7115
Mailing Address - Fax:212-585-2178
Practice Address - Street 1:16 E 79TH ST
Practice Address - Street 2:SUITE 42
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-0150
Practice Address - Country:US
Practice Address - Phone:212-794-7115
Practice Address - Fax:212-585-2178
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1488332084P0800X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Not Answered2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01127682Medicaid
NY29E013Medicare ID - Type Unspecified
NYB12342Medicare UPIN