Provider Demographics
NPI:1912974163
Name:HALL, JONATHAN DANIEL (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DANIEL
Last Name:HALL
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 1:92 MONTVALE AVE
Mailing Address - Street 2:SUITE 3300
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-3647
Mailing Address - Country:US
Mailing Address - Phone:781-279-7930
Mailing Address - Fax:781-279-2368
Practice Address - Street 1:92 MONTVALE AVE.
Practice Address - Street 2:SUITE 3300
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180
Practice Address - Country:US
Practice Address - Phone:781-249-7930
Practice Address - Fax:781-249-2368
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-07
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA729072086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
E49123Medicare UPIN
J09796Medicare ID - Type Unspecified