Healthcare Provider Details

I. General information

NPI: 1134135155
Provider Name (Legal Business Name): JONATHAN NISSANOFF MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15525 POMERADO RD STE E6
POWAY CA
92064-2427
US

IV. Provider business mailing address

PO BOX 502530
SAN DIEGO CA
92150-2530
US

V. Phone/Fax

Practice location:
  • Phone: 858-451-2280
  • Fax: 858-451-2006
Mailing address:
  • Phone: 858-451-2280
  • Fax: 858-451-2006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG82348
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: