Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 000762 | CT |
N | 111NR0400X | Rehabilitation Chiropractor | 000762 | CT |
NPI | 1245364017 |
---|---|
Provider Name | Dr. Jonathan Peter Konecny |
First Address | Bridgeport, CT 06604-1915 |
Second Address | Bridgeport, CT 06604-1915 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/03/2007 |
Last Update Date | 07/04/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
UO1596 | (02) | CT |