Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | DS024789L | PA |
NPI | 1154358042 |
---|---|
Provider Name | Jonathan Mark Korostoff |
First Address | Philadelphia, PA 19104-4206 |
Second Address | Philadelphia, PA 19104-4206 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/06/2006 |
Last Update Date | 02/04/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0014770200001 | (05) | PA |
U42313 | (02) |