Provider Demographics
NPI:1285922724
Name:TANNEBAUM, JONATHAN ETHAN (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:ETHAN
Last Name:TANNEBAUM
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:908 NIAGARA FALLS BLVD STE 208
Mailing Address - Street 2:
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-2019
Mailing Address - Country:US
Mailing Address - Phone:716-692-3302
Mailing Address - Fax:716-692-4342
Practice Address - Street 1:251 N 4TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:MD
Practice Address - Zip Code:21550-1375
Practice Address - Country:US
Practice Address - Phone:301-533-4000
Practice Address - Fax:301-895-8751
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY275818208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1H0698OtherMEDICAR PTAN
MD996022880Medicaid