Provider Demographics
NPI:1437151537
Name:MICHNOVICZ, JON (MD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:
Last Name:MICHNOVICZ
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 1:90 WINDSOR AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-5714
Mailing Address - Country:US
Mailing Address - Phone:718-855-7707
Mailing Address - Fax:516-594-6687
Practice Address - Street 1:177 LIVINGSTON STREET
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5875
Practice Address - Country:US
Practice Address - Phone:718-855-7707
Practice Address - Fax:718-855-7717
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-02
Last Update Date:2024-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY163890174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01457354Medicaid
NY01457354Medicaid
NY10E111Medicare PIN
NYA99819Medicare UPIN