Healthcare Provider Details

I. General information

NPI: 1124065891
Provider Name (Legal Business Name): JONATHAN THOMAS MEGERIAN M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: TOM MEGERIAN MD, PHD

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 07/06/2020
Certification Date: 07/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 S MAIN ST
ORANGE CA
92868-2801
US

IV. Provider business mailing address

6 NANCYS WAY
LITTLETON MA
01460-1439
US

V. Phone/Fax

Practice location:
  • Phone: 714-288-7651
  • Fax:
Mailing address:
  • Phone: 617-293-9370
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number81401
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number81401
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number81401
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: