Provider Demographics
NPI:1376974261
Name:ITZCHAKOV, JONATHAN
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:
Last Name:ITZCHAKOV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JONATHAN
Other - Middle Name:
Other - Last Name:ITZCHAKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14431 70TH AVE
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-1713
Mailing Address - Country:US
Mailing Address - Phone:718-487-3397
Mailing Address - Fax:
Practice Address - Street 1:35 EASON DR
Practice Address - Street 2:
Practice Address - City:RIDGE
Practice Address - State:NY
Practice Address - Zip Code:11961-3111
Practice Address - Country:US
Practice Address - Phone:631-345-6501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-03
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program