Provider Demographics
NPI:1043215841
Name:MOLDOVER, JONATHAN R (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:R
Last Name:MOLDOVER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:280 CHESTNUT ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01199-1001
Mailing Address - Country:US
Mailing Address - Phone:413-794-5700
Mailing Address - Fax:
Practice Address - Street 1:21 DWIGHT ROAD
Practice Address - Street 2:STE 104
Practice Address - City:LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01106
Practice Address - Country:US
Practice Address - Phone:413-794-5600
Practice Address - Fax:413-794-2733
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA2627552081P2900X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C29499Medicare UPIN
NY00427596Medicaid
04L591Medicare ID - Type Unspecified