Provider Demographics
NPI:1215909072
Name:PUCHALSKI, JONATHAN THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:THOMAS
Last Name:PUCHALSKI
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 1:330 CEDAR ST
Mailing Address - Street 2:BOARDMAN BUILDING RM 205
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3218
Mailing Address - Country:US
Mailing Address - Phone:203-688-5864
Mailing Address - Fax:
Practice Address - Street 1:330 CEDAR ST
Practice Address - Street 2:BOARDMAN BUILDING RM 205
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3218
Practice Address - Country:US
Practice Address - Phone:203-688-5864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2010-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT047218207RC0200X, 207RP1001X
OH35077075207RP1001X
PAMD432420207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2360761Medicaid
7306791Medicare ID - Type Unspecified
H73792Medicare UPIN