Provider Demographics
NPI:1922004241
Name:DAVID, JONATHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:DAVID
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 1:136 SAGAMORE RD
Mailing Address - Street 2:
Mailing Address - City:TUCKAHOE
Mailing Address - State:NY
Mailing Address - Zip Code:10707-4009
Mailing Address - Country:US
Mailing Address - Phone:914-337-6400
Mailing Address - Fax:914-337-8019
Practice Address - Street 1:136 SAGAMORE RD
Practice Address - Street 2:
Practice Address - City:TUCKAHOE
Practice Address - State:NY
Practice Address - Zip Code:10707-4009
Practice Address - Country:US
Practice Address - Phone:914-337-6400
Practice Address - Fax:914-337-8019
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY178695207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF55707Medicare UPIN
NY60H121Medicare ID - Type Unspecified