Healthcare Provider Details

I. General information

NPI: 1144848201
Provider Name (Legal Business Name): JONATHAN KIRIBOON OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2020
Last Update Date: 06/27/2025
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3329 TWEEDY BLVD
SOUTH GATE CA
90280-4324
US

IV. Provider business mailing address

3329 TWEEDY BLVD
SOUTH GATE CA
90280-4324
US

V. Phone/Fax

Practice location:
  • Phone: 323-566-6183
  • Fax:
Mailing address:
  • Phone: 323-566-6183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number34620
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: