Healthcare Provider Details

I. General information

NPI: 1306813332
Provider Name (Legal Business Name): JONATHAN DANIEL WASSERMAN M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 10/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 UNIVERSITY AVENUE
TORONTO ONTARIO
M5G 1X8
CA

IV. Provider business mailing address

555 UNIVERSITY AVENUE
TORONTO ONTARIO
M5G 1X8
CA

V. Phone/Fax

Practice location:
  • Phone: 416-813-7654
  • Fax: 416-813-6304
Mailing address:
  • Phone: 416-813-7654
  • Fax: 416-813-6304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number217797
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number88468
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: