Basic Information
| Provider Information | |||||||||
| NPI: | 1255344099 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARCUS | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 278984 | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146278984 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852750275 | ||||||||
| FaxNumber: | 5852731255 | ||||||||
| Practice Location | |||||||||
| Address1: | 919 WESTFALL RD | ||||||||
| Address2: | BLDG C-215 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146182627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853417420 | ||||||||
| FaxNumber: | 5852731255 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 03/01/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 256218-1 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | J400029596 | 01 | NY | MEDICARE PTAN | OTHER |