Provider Demographics
NPI:1265536635
Name:BEITLER, JONATHAN JAY (MD, MBA, FACR)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:JAY
Last Name:BEITLER
Suffix:
Gender:M
Credentials:MD, MBA, FACR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 OGDEN RD
Mailing Address - Street 2:
Mailing Address - City:NEW CANAAN
Mailing Address - State:CT
Mailing Address - Zip Code:06840-2210
Mailing Address - Country:US
Mailing Address - Phone:203-972-0160
Mailing Address - Fax:
Practice Address - Street 1:1365 CLIFTON RD NE
Practice Address - Street 2:DEPARTMENT OF RADIATION ONCOLOGY
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-1013
Practice Address - Country:US
Practice Address - Phone:404-778-5525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1545012083A0100X, 2085R0001X
CT0438002085R0001X, 2083A0100X
CAG630322085R0001X
GA600432085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01191322Medicaid
GA467640604CMedicaid
GA467640604CMedicaid
NY01191322Medicaid
NYJB061F4710Medicare ID - Type Unspecified