Healthcare Provider Details

I. General information

NPI: 1255765020
Provider Name (Legal Business Name): JONATHAN MAYNARD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2013
Last Update Date: 08/08/2024
Certification Date: 08/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18102 CULVER DR
IRVINE CA
92612-2730
US

IV. Provider business mailing address

18102 CULVER DR
IRVINE CA
92612-2730
US

V. Phone/Fax

Practice location:
  • Phone: 657-241-8220
  • Fax:
Mailing address:
  • Phone: 657-241-8220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA136798
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: