Provider Demographics
NPI:1811975493
Name:MARDIROSSIAN, JONATHAN (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:MARDIROSSIAN
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 1:12 MAPLEMOOR LANE
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10605-4704
Mailing Address - Country:US
Mailing Address - Phone:914-684-0020
Mailing Address - Fax:
Practice Address - Street 1:12 MAPLEMOOR LANE
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10605-4704
Practice Address - Country:US
Practice Address - Phone:914-684-0020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03332300207W00000X
CAG031724207W00000X
NY116323207W00000X
IN01028855A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00752694Medicaid
P00278038OtherRAILROAD MEDICARE
NYP3007526949Medicaid
71A521Medicare ID - Type Unspecified
NYP3007526949Medicaid