Provider Demographics
NPI:1245203066
Name:PRENNER, JONATHAN L (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:L
Last Name:PRENNER
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 1:1000 GALLOPING HILL RD STE 305
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083-7991
Mailing Address - Country:US
Mailing Address - Phone:908-458-8333
Mailing Address - Fax:908-458-8339
Practice Address - Street 1:10 PLUM STREET
Practice Address - Street 2:SUITE 600
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901
Practice Address - Country:US
Practice Address - Phone:732-220-1600
Practice Address - Fax:732-220-1603
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2017-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07734200207W00000X
NJ25MA07110100207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0097641Medicaid
H66443Medicare UPIN
NJ0097641Medicaid