Provider Demographics
NPI:1568025401
Name:KOPPEL, JONATHAN RONSON
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:RONSON
Last Name:KOPPEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 PARK AVE APT 15A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-4946
Mailing Address - Country:US
Mailing Address - Phone:516-359-2008
Mailing Address - Fax:
Practice Address - Street 1:2109 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-2138
Practice Address - Country:US
Practice Address - Phone:212-523-8672
Practice Address - Fax:212-492-5505
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-16
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY315668207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program