Healthcare Provider Details

I. General information

NPI: 1801578414
Provider Name (Legal Business Name): JONATHAN MAO DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2023
Last Update Date: 08/02/2023
Certification Date: 08/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12400 SANTA MONICA BLVD
LOS ANGELES CA
90025-2522
US

IV. Provider business mailing address

789 FRESCA DR
OXNARD CA
93030-0163
US

V. Phone/Fax

Practice location:
  • Phone: 310-264-8385
  • Fax:
Mailing address:
  • Phone: 805-815-7689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number304346
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: