Basic Information
| Provider Information | |||||||||
| NPI: | 1306172689 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOLDENTHAL | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | JACOB | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 242 MASON AVE | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103053408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182266522 | ||||||||
| FaxNumber: | 7182266531 | ||||||||
| Practice Location | |||||||||
| Address1: | 242 MASON AVE | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103053408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182266522 | ||||||||
| FaxNumber: | 7182266531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2009 | ||||||||
| LastUpdateDate: | 03/16/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 247621 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 03420197 | 05 | NY | MEDICAID |