Provider Demographics
NPI:1790821239
Name:THALER, JONATHAN S (NYS LAC)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:S
Last Name:THALER
Suffix:
Gender:M
Credentials:NYS LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 NORTH RIDGE RD. ,POB 611
Mailing Address - Street 2:POB 611
Mailing Address - City:SHRUB OAK
Mailing Address - State:NY
Mailing Address - Zip Code:10588-0611
Mailing Address - Country:US
Mailing Address - Phone:914-528-8770
Mailing Address - Fax:
Practice Address - Street 1:1220 N RIDGE RD
Practice Address - Street 2:POB 611
Practice Address - City:SHRUB OAK
Practice Address - State:NY
Practice Address - Zip Code:10588-1033
Practice Address - Country:US
Practice Address - Phone:914-528-8770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000697171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist