Healthcare Provider Details

I. General information

NPI: 1467960690
Provider Name (Legal Business Name): JONATHAN TAVAKOLI DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2018
Last Update Date: 01/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11932 GOSHEN AVE PH 1
LOS ANGELES CA
90049-7309
US

IV. Provider business mailing address

11932 GOSHEN AVE PH 1
LOS ANGELES CA
90049-7309
US

V. Phone/Fax

Practice location:
  • Phone: 310-651-0098
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE5422
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: