Provider Demographics
NPI:1245256528
Name:JELLINEK, NATHANIEL JOSEF (MD)
Entity type:Individual
Prefix:DR
First Name:NATHANIEL
Middle Name:JOSEF
Last Name:JELLINEK
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 1:1672 S COUNTY TRL
Mailing Address - Street 2:SUITE 101
Mailing Address - City:EAST GREENWICH
Mailing Address - State:RI
Mailing Address - Zip Code:02818-5098
Mailing Address - Country:US
Mailing Address - Phone:404-885-6647
Mailing Address - Fax:401-885-6639
Practice Address - Street 1:1672 S COUNTY TRL
Practice Address - Street 2:SUITE 101
Practice Address - City:EAST GREENWICH
Practice Address - State:RI
Practice Address - Zip Code:02818-5098
Practice Address - Country:US
Practice Address - Phone:404-885-6647
Practice Address - Fax:401-885-6639
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI11514207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RINJ53855Medicaid
RII09140Medicare UPIN
RI007057634Medicare PIN