Provider Demographics
NPI:1245228246
Name:KNISELY, JONATHAN PS (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:PS
Last Name:KNISELY
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 1:525 EAST 68TH STREET
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065
Mailing Address - Country:US
Mailing Address - Phone:212-746-3610
Mailing Address - Fax:127-746-8749
Practice Address - Street 1:525 E 68TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065
Practice Address - Country:US
Practice Address - Phone:212-746-3610
Practice Address - Fax:212-746-8749
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0323302085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001323302Medicaid
CT300001316Medicare ID - Type Unspecified
F29066Medicare UPIN