Healthcare Provider Details

I. General information

NPI: 1831204627
Provider Name (Legal Business Name): JONATHAN WANAGAT MD PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 02/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MEDICAL PLZ SUITE 420
LOS ANGELES CA
90095-0001
US

IV. Provider business mailing address

5767 W CENTURY BLVD 200
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-206-2583
  • Fax: 310-794-2199
Mailing address:
  • Phone: 310-206-7272
  • Fax: 310-794-2113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberA107495
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: