Provider Demographics
NPI:1871575647
Name:ALTUS, JONATHAN DREW (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DREW
Last Name:ALTUS
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 1:920 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:11510-4241
Mailing Address - Country:US
Mailing Address - Phone:516-623-8700
Mailing Address - Fax:516-623-3746
Practice Address - Street 1:920 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:BALDWIN HARBOR
Practice Address - State:NY
Practice Address - Zip Code:11510-4241
Practice Address - Country:US
Practice Address - Phone:516-623-8700
Practice Address - Fax:516-623-3746
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY164913207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01144018Medicaid
NYA400118179Medicare PIN
E17205Medicare UPIN