Provider Demographics
NPI:1891792255
Name:GUSDORFF, JONATHAN (DO)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:GUSDORFF
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 W CHESTER PIKE
Mailing Address - Street 2:
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083-2929
Mailing Address - Country:US
Mailing Address - Phone:610-482-4949
Mailing Address - Fax:610-482-4950
Practice Address - Street 1:1305 W CHESTER PIKE
Practice Address - Street 2:
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-2929
Practice Address - Country:US
Practice Address - Phone:610-482-4949
Practice Address - Fax:610-482-4950
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02005865A2085N0700X
OK45192085R0202X
PAOS010370L174400000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200114580AMedicaid
OK249722804Medicare PIN
OK200114580AMedicaid
OKP00412488Medicare PIN