Basic Information
Provider Information | |||||||||
NPI: | 1609070671 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BERKOWITZ | ||||||||
FirstName: | JONATHAN | ||||||||
MiddleName: | LAURENCE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D., PH.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1200 W WHITE RIVER BLVD | ||||||||
Address2: | RCS PROVIDER ENROLLMENT | ||||||||
City: | MUNCIE | ||||||||
State: | IN | ||||||||
PostalCode: | 473034988 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7652544009 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2401 W UNIVERSITY AVE | ||||||||
Address2: |   | ||||||||
City: | MUNCIE | ||||||||
State: | IN | ||||||||
PostalCode: | 47303 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7652812030 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/13/2007 | ||||||||
LastUpdateDate: | 03/04/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0000X | 01081263A | IN | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology | 207RH0003X | A116529 | CA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RX0202X | 01081263A | IN | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
ID | Type | State | Issuer | Description | 300020674 | 05 | IN |   | MEDICAID |