MEDICARE: JONATHAN NASSOS PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician

General Provider Information

NPI Number	:	1578810339
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JONATHAN NASSOS PC

Provider Business Mailing Address
First Line	:	5651 SEPULVEDA BLVD
Second Line	:	SUITE 201
City	:	SHERMAN OAKS
State	:	CA
Zip	:	91411-2916
Country	:	US
Telephone Number	:	818-788-2400
Fax Number	:	818-788-2453

Provider Business Practice Location Address
First Line	:	5651 SEPULVEDA BLVD
Second Line	:	SUITE 201
City	:	SHERMAN OAKS
State	:	CA
Zip	:	91411-2916
Country	:	US
Telephone Number	:	818-788-2400
Fax Number	:	818-788-2400

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	JONATHAN T NASSOS
Credential	:	MD
Telephone Number	:	310-273-2731

Provider Enumeration Date	:	08/12/2012
Last Update Date	:	07/07/2014

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