Provider Demographics
NPI:1467484394
Name:SUSMAN, JONATHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:SUSMAN
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 1:622 W 168TH ST
Mailing Address - Street 2:MC# 28
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3720
Mailing Address - Country:US
Mailing Address - Phone:212-305-1948
Mailing Address - Fax:212-305-5777
Practice Address - Street 1:622 W 168TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3720
Practice Address - Country:US
Practice Address - Phone:212-305-9335
Practice Address - Fax:212-305-8636
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203180-12085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW35021OtherMEDICARE GROUP#
NY1467560854OtherGROUP NPI #
NYW34991OtherMEDICARE GROUP#
NY02186161OtherMEDICAID GROUP#
NY02186203OtherMEDICAID GROUP#
NY1992816011OtherGROUP NPI#
NY02007454Medicaid
NY02186203OtherMEDICAID GROUP#
NYW34991OtherMEDICARE GROUP#