Healthcare Provider Details

I. General information

NPI: 1124515739
Provider Name (Legal Business Name): JONATHAN LIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2018
Last Update Date: 10/15/2024
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

757 WESTWOOD PLZ STE 1638
LOS ANGELES CA
90095-8358
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-267-8758
  • Fax:
Mailing address:
  • Phone: 310-301-8707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA164656
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: