Healthcare Provider Details

I. General information

NPI: 1386073377
Provider Name (Legal Business Name): JONATHAN CORREN MD, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2013
Last Update Date: 11/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10780 SANTA MONICA BLVD SUITE #280
LOS ANGELES CA
90025-4749
US

IV. Provider business mailing address

10780 SANTA MONICA BLVD SUITE #280
LOS ANGELES CA
90025-4749
US

V. Phone/Fax

Practice location:
  • Phone: 310-312-5050
  • Fax: 310-575-9292
Mailing address:
  • Phone: 310-312-5050
  • Fax: 310-575-9292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KI0005X
TaxonomyClinical & Laboratory Immunology (Allergy & Immunology) Physician
License NumberG53016
License Number StateCA

VIII. Authorized Official

Name: JONATHAN CORREN
Title or Position: PRESIDENT
Credential: MD
Phone: 310-312-5050