Provider Demographics
NPI:1700010774
Name:MEZRICH, JONATHAN LEE (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:LEE
Last Name:MEZRICH
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 1:22 S GREENE ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-1544
Mailing Address - Country:US
Mailing Address - Phone:410-916-5271
Mailing Address - Fax:
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-916-5271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-06
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00744922085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology