Healthcare Provider Details

I. General information

NPI: 1891478111
Provider Name (Legal Business Name): JONATHAN TAVAKOLI DPM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2023
Last Update Date: 02/13/2024
Certification Date: 02/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10518 WILKINS AVE
LOS ANGELES CA
90024-6032
US

IV. Provider business mailing address

10518 WILKINS AVE
LOS ANGELES CA
90024-6032
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JONATHAN TAVAKOLI
Title or Position: CEO
Credential: DPM
Phone: 310-651-0098