Provider Demographics
NPI:1124078589
Name:BUSCAGLIA, JONATHAN MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:MICHAEL
Last Name:BUSCAGLIA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 TECHNOLOGY DRIVE
Mailing Address - Street 2:STONY BROOK UNIVERSITY PHYSICIANS
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733
Mailing Address - Country:US
Mailing Address - Phone:631-444-5220
Mailing Address - Fax:631-444-5225
Practice Address - Street 1:3 TECHNOLOGY DRIVE
Practice Address - Street 2:STONY BROOK UNIVERSITY PHYSICIANS
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733
Practice Address - Country:US
Practice Address - Phone:631-444-5220
Practice Address - Fax:631-444-5225
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0063684207R00000X
MDD63684207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD409447600Medicaid
MDS589 N526Medicare ID - Type Unspecified
MDI48290Medicare UPIN