Provider Demographics
NPI:1790754976
Name:RAANAN, JONATHAN L (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:L
Last Name:RAANAN
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 1:24 RESEARCH WAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-3453
Mailing Address - Country:US
Mailing Address - Phone:631-444-1210
Mailing Address - Fax:631-444-1535
Practice Address - Street 1:24 RESEARCH WAY
Practice Address - Street 2:SUITE 200
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-3453
Practice Address - Country:US
Practice Address - Phone:631-444-1210
Practice Address - Fax:631-444-1535
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY226609-1208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0361131251Medicaid
ILK19179Medicare ID - Type Unspecified
IL0361131251Medicaid