Provider Demographics
NPI:1033768817
Name:CASAZOLA, JONATHAN
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:CASAZOLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 746087
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6087
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:773-866-8014
Practice Address - Street 1:1953 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-4404
Practice Address - Country:US
Practice Address - Phone:718-765-6054
Practice Address - Fax:347-706-3912
Is Sole Proprietor?:No
Enumeration Date:2019-09-05
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY328395207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program