Healthcare Provider Details

I. General information

NPI: 1053668434
Provider Name (Legal Business Name): JONATHAN OLUMOYA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2012
Last Update Date: 07/14/2021
Certification Date: 07/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 S SAN PEDRO ST
LOS ANGELES CA
90011-2023
US

IV. Provider business mailing address

2801 S SAN PEDRO ST
LOS ANGELES CA
90011-2023
US

V. Phone/Fax

Practice location:
  • Phone: 323-233-3100
  • Fax: 323-233-4100
Mailing address:
  • Phone: 323-233-3100
  • Fax: 323-233-4100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA131566
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: