Provider Demographics
NPI:1679551469
Name:DEITCH, JONATHAN S (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:S
Last Name:DEITCH
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 1:1325 PENNSYLVANIA AVE STE 680
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2133
Mailing Address - Country:US
Mailing Address - Phone:817-250-4235
Mailing Address - Fax:
Practice Address - Street 1:1325 PENNSYLVANIA AVE STE 680
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2133
Practice Address - Country:US
Practice Address - Phone:817-250-4235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY194966-12086S0129X
TXT36102086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01921764Medicaid
NY01921764Medicaid
NYG86999Medicare UPIN