Healthcare Provider Details

I. General information

NPI: 1346668779
Provider Name (Legal Business Name): JONATHAN ALLEN KORETOFF M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2014
Last Update Date: 01/10/2025
Certification Date: 01/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10505 SORRENTO VALLEY RD STE 200
SAN DIEGO CA
92121-1619
US

IV. Provider business mailing address

10505 SORRENTO VALLEY RD STE 200
SAN DIEGO CA
92121-1619
US

V. Phone/Fax

Practice location:
  • Phone: 858-793-7860
  • Fax:
Mailing address:
  • Phone: 858-793-7860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberA157665
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: