Provider Demographics
NPI:1588638142
Name:WEBER, JONATHAN (DPM)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:WEBER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2315 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6623
Mailing Address - Country:US
Mailing Address - Phone:718-477-6900
Mailing Address - Fax:718-983-0352
Practice Address - Street 1:2315 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6623
Practice Address - Country:US
Practice Address - Phone:718-477-6900
Practice Address - Fax:718-983-0352
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005521213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY005521-A11OtherHEALTHFIRST ID#
NY2702523OtherEVERCARE ID#
NY009127301OtherAMERICHOICE #
NY01977980Medicaid
NYP3711260OtherOXFORD
NY0130341OtherGHI PPO
NY5C8712OtherHEALTHNET
NYPK8941OtherEMPIRE BCBS
NY134114612OtherTAX IDENTIFICATION NUMBER
NYN005521OtherHIP
NYWJ5521OtherATLANTIS HEALTH PLAN
NY7772241OtherAETNA PPO#
NY7772241OtherAETNA PPO#
NYU74332Medicare UPIN