Healthcare Provider Details

I. General information

NPI: 1487607685
Provider Name (Legal Business Name): JONATHAN TORREGOSA TIONGSON DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 11/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11633 SAN VICENTE BLVD SUITE 200
LOS ANGELES CA
90049-6511
US

IV. Provider business mailing address

11633 SAN VICENTE BLVD SUITE 200
LOS ANGELES CA
90049-6511
US

V. Phone/Fax

Practice location:
  • Phone: 310-442-1975
  • Fax: 310-442-1977
Mailing address:
  • Phone: 310-442-1975
  • Fax: 310-442-1977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE4600
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: