Provider Demographics
NPI:1841266475
Name:ZIMMERMAN, JONATHAN LANDIS (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:LANDIS
Last Name:ZIMMERMAN
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 1:10 HELLBROOK LN
Mailing Address - Street 2:
Mailing Address - City:ULSTER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12487-5209
Mailing Address - Country:US
Mailing Address - Phone:845-658-7763
Mailing Address - Fax:
Practice Address - Street 1:1001 BROADWAY STE 223
Practice Address - Street 2:
Practice Address - City:ESOPUS
Practice Address - State:NY
Practice Address - Zip Code:12429-2500
Practice Address - Country:US
Practice Address - Phone:845-658-7763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY180313207Q00000X
PAMD043137L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY193813OtherHMO ULSTER PARK NUMBER
PAMD043137LOtherLICENSE
NY02160103Medicaid
NY180313OtherNY LICENSE NUMBER
NY217168OtherHMO ELKA PARK NUMBER
PA001676516-0005Medicaid
PA001676516-0005Medicaid
NYBZ9220043OtherDEA ELKA PARK
NY5D6841Medicare ID - Type Unspecified
NY193813OtherHMO ULSTER PARK NUMBER
PA001676516-0005Medicaid