Healthcare Provider Details

I. General information

NPI: 1043469901
Provider Name (Legal Business Name): MR. JONATHAN FIDANI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2008
Last Update Date: 09/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 PASADENA AVE
SOUTH PASADENA CA
91030-2919
US

IV. Provider business mailing address

1143 E JUANITA AVE
GLENDORA CA
91740-6106
US

V. Phone/Fax

Practice location:
  • Phone: 323-344-5541
  • Fax: 323-344-5550
Mailing address:
  • Phone: 626-857-7755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: