Basic Information
| Provider Information | |||||||||
| NPI: | 1891724290 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TICKER | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 660 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | MASSAPEQUA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117582312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5167980111 | ||||||||
| FaxNumber: | 5167980152 | ||||||||
| Practice Location | |||||||||
| Address1: | 660 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | MASSAPEQUA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117582312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5167980111 | ||||||||
| FaxNumber: | 5167980152 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 11/09/2009 | ||||||||
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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 | 207X00000X | 180039 | NY | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1309558 | 01 | NY | CIGNA | OTHER | AA47457 | 01 | NY | MDNY | OTHER | 35497526 | 01 | NY | MULTIPLAN | OTHER | AS1634 | 01 | NY | OXFORD | OTHER | 1570938 | 05 | NY | MEDICAID | 2000021570 | 01 | NY | RR MEDICARE | OTHER | 501030 | 01 | NY | GHI CBP | OTHER | 010180039NY | 01 | NY | ANTHEM | OTHER | 531270 | 01 | NY | AETNA US HEALTHCARE | OTHER | 5103229 | 01 | NY | AETNA PPO | OTHER | 1044724 | 01 | NY | FIRST HEALTH | OTHER | 1445199 | 01 | NY | UNITED | OTHER | 30293P | 01 | NY | HIP | OTHER | 180039S | 01 | NY | HEALTHCARE PARTNERS | OTHER | GHI PPO | 01 | NY | 0501005 | OTHER | 1C0831 | 01 | NY | HEALTHNET | OTHER | 60G781 | 01 | NY | BLUE CROSS BLUE SHIELD | OTHER | 68711 | 01 | NY | GHI HMO | OTHER |