Provider Demographics
NPI:1275814618
Name:KHODADADIAN, JONATHAN J (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:J
Last Name:KHODADADIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:150 E SUNRISE HWY
Mailing Address - Street 2:208
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-2539
Mailing Address - Country:US
Mailing Address - Phone:631-225-7200
Mailing Address - Fax:631-930-9451
Practice Address - Street 1:150 E SUNRISE HWY
Practice Address - Street 2:208
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-2539
Practice Address - Country:US
Practice Address - Phone:631-225-7200
Practice Address - Fax:631-930-9451
Is Sole Proprietor?:No
Enumeration Date:2011-08-30
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY265565207UN0902X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & Therapy
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program