Provider Demographics
NPI:1316034481
Name:VICTOR, JONATHAN D (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:D
Last Name:VICTOR
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 1:520 E 70TH ST # STARR-607
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-9800
Mailing Address - Country:US
Mailing Address - Phone:212-746-0373
Mailing Address - Fax:212-746-7481
Practice Address - Street 1:520 E 70TH ST # STARR-607
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-9800
Practice Address - Country:US
Practice Address - Phone:212-746-2340
Practice Address - Fax:212-746-8532
Is Sole Proprietor?:No
Enumeration Date:2006-10-09
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1465052084N0400X, 2084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00983160Medicaid
NYC12171Medicare UPIN
NY00983160Medicaid