Provider Demographics
NPI:1902993397
Name:NATHANIEL, ROGER (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:NATHANIEL
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 1:135 CENTRAL PARK W
Mailing Address - Street 2:SUITE 1NW
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-2413
Mailing Address - Country:US
Mailing Address - Phone:212-799-6200
Mailing Address - Fax:212-873-4268
Practice Address - Street 1:135 CENTRAL PARK W
Practice Address - Street 2:SUITE 1NW
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-2413
Practice Address - Country:US
Practice Address - Phone:212-799-6200
Practice Address - Fax:212-873-4268
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1526162084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB20168Medicare UPIN