Provider Demographics
NPI:1962572552
Name:VENEGAS, JONATHAN ADAM (PT)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:ADAM
Last Name:VENEGAS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 RELLIM DR
Mailing Address - Street 2:
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-4023
Mailing Address - Country:US
Mailing Address - Phone:516-801-0779
Mailing Address - Fax:516-781-1013
Practice Address - Street 1:1651 BELLMORE AVE
Practice Address - Street 2:
Practice Address - City:NORTH BELLMORE
Practice Address - State:NY
Practice Address - Zip Code:11710-5526
Practice Address - Country:US
Practice Address - Phone:516-781-1085
Practice Address - Fax:516-781-1013
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015585-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA3394616OtherOXFORD
NY1877505OtherUNITED HEALTH CARE
NYA3394616OtherOXFORD
NYQ06E81Medicare ID - Type UnspecifiedEMPIRE MEDICARE