Provider Demographics
NPI:1871604025
Name:LOWELL, JONATHAN (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:LOWELL
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 1:130 PARK STREET
Mailing Address - Street 2:
Mailing Address - City:MALONE
Mailing Address - State:NY
Mailing Address - Zip Code:12953
Mailing Address - Country:US
Mailing Address - Phone:518-483-1120
Mailing Address - Fax:518-483-9419
Practice Address - Street 1:130 PARK STREET
Practice Address - Street 2:
Practice Address - City:MALONE
Practice Address - State:NY
Practice Address - Zip Code:12953
Practice Address - Country:US
Practice Address - Phone:518-483-1120
Practice Address - Fax:518-483-9419
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY134140207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA81036OtherFR CO NURSING HOME
NY00632655Medicaid
NY00632655Medicaid
NY53689AMedicare PIN
B80166Medicare UPIN