=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649482019
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN TEPPER M.D., PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 240 WESTGATE DR STE 122
-----------------------------------------------------
City | WATSONVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95076-2453
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-728-3939
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 436 SNYDER AVE
-----------------------------------------------------
City | AROMAS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95004-9516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-726-9258
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | G52668
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------