Provider Demographics
NPI:1205826609
Name:ATHAS, JOHN M (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:ATHAS
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 1:325 5TH AVE
Mailing Address - Street 2:SUITE 45A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-5038
Mailing Address - Country:US
Mailing Address - Phone:212-532-4590
Mailing Address - Fax:917-595-5325
Practice Address - Street 1:325 5TH AVE
Practice Address - Street 2:SUITE 45A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-5038
Practice Address - Country:US
Practice Address - Phone:212-532-4590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD335782085N0700X, 2085R0202X
NY241191174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02888351Medicaid
009458C91Medicare ID - Type Unspecified
NY8428URMedicare PIN
NY552231Medicare PIN
NY02888351Medicaid