Healthcare Provider Details

I. General information

NPI: 1255302287
Provider Name (Legal Business Name): JONATHAN DANIEL PAUL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2006
Last Update Date: 09/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 COLCHESTER AVE
BURLINGTON VT
05401
US

IV. Provider business mailing address

100 EAST CALIFORNIA BLVD
PASADENA CA
91105-3205
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-3843
  • Fax: 802-847-1481
Mailing address:
  • Phone: 626-269-5317
  • Fax: 626-577-2100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number042.0012437
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number49087
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License Number148289
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: