Provider Demographics
NPI:1184621906
Name:SUMBER, JONATHAN PAUL (DPM)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:PAUL
Last Name:SUMBER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3451
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12402-3451
Mailing Address - Country:US
Mailing Address - Phone:845-331-0601
Mailing Address - Fax:845-331-0601
Practice Address - Street 1:190 FAIR ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-4502
Practice Address - Country:US
Practice Address - Phone:845-331-0601
Practice Address - Fax:845-331-0601
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004351-1213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01094059Medicaid
NYPPW071Medicare PIN
NY4690380001Medicare NSC
NY01094059Medicaid