Provider Demographics
NPI:1144416058
Name:BACHARACH, JONATHAN N (DPT)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:N
Last Name:BACHARACH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6319 FLY RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-9326
Mailing Address - Country:US
Mailing Address - Phone:315-410-6200
Mailing Address - Fax:315-451-2095
Practice Address - Street 1:897 BROADWAY
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-1205
Practice Address - Country:US
Practice Address - Phone:212-673-7878
Practice Address - Fax:212-674-7878
Is Sole Proprietor?:No
Enumeration Date:2007-09-25
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029697-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ8512QA561Medicare PIN