Healthcare Provider Details

I. General information

NPI: 1225390347
Provider Name (Legal Business Name): JONATHAN FREDERIC WEBER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2012
Last Update Date: 11/29/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 W SUNSET BLVD
LOS ANGELES CA
90027-6062
US

IV. Provider business mailing address

4650 W SUNSET BLVD
LOS ANGELES CA
90027-6062
US

V. Phone/Fax

Practice location:
  • Phone: 323-361-4606
  • Fax:
Mailing address:
  • Phone: 323-361-3386
  • Fax: 323-361-1301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125-061245
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: