Provider Demographics
NPI: | 1639136872 |
---|---|
Name: | SIUTA, JONATHAN RICHARD (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | JONATHAN |
Middle Name: | RICHARD |
Last Name: | SIUTA |
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: | 1800 E PARK AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | STATE COLLEGE |
Mailing Address - State: | PA |
Mailing Address - Zip Code: | 16803-6709 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 814-278-4818 |
Mailing Address - Fax: | 814-234-6150 |
Practice Address - Street 1: | 1800 E PARK AVE |
Practice Address - Street 2: | |
Practice Address - City: | STATE COLLEGE |
Practice Address - State: | PA |
Practice Address - Zip Code: | 16803-6709 |
Practice Address - Country: | US |
Practice Address - Phone: | 814-278-4818 |
Practice Address - Fax: | 814-234-6150 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-05-01 |
Last Update Date: | 2015-03-20 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
PA | MD449631 | 207R00000X, 208000000X, 208M00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist | |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
PA | I49814 | Medicare UPIN |