=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578810339
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JONATHAN NASSOS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2012
-----------------------------------------------------
Last Update Date | 07/07/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5651 SEPULVEDA BLVD SUITE 201
-----------------------------------------------------
City | SHERMAN OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91411-2916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-788-2400
-----------------------------------------------------
Fax | 818-788-2400
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5651 SEPULVEDA BLVD SUITE 201
-----------------------------------------------------
City | SHERMAN OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91411-2916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-788-2400
-----------------------------------------------------
Fax | 818-788-2453
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | JONATHAN T NASSOS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 310-273-2731
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XX0005X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------