Provider Demographics
NPI:1164616603
Name:JONATHAN R MOLDOVER MD LLC
Entity Type:Organization
Organization Name:JONATHAN R MOLDOVER MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOLDOVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-581-4488
Mailing Address - Street 1:200 W 57TH ST
Mailing Address - Street 2:SUITE 608
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-3211
Mailing Address - Country:US
Mailing Address - Phone:212-581-4488
Mailing Address - Fax:
Practice Address - Street 1:200 W 57TH ST
Practice Address - Street 2:SUITE 608
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-3211
Practice Address - Country:US
Practice Address - Phone:212-581-4488
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-28
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWEK521Medicare PIN