MEDICARE: DR. JONATHAN OLUMOYA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	A131566	CA

General Provider Information

NPI Number	:	1053668434
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN OLUMOYA M.D.

Provider Business Mailing Address
First Line	:	2801 S SAN PEDRO ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90011-2023
Country	:	US
Telephone Number	:	323-233-3100
Fax Number	:	323-233-4100

Provider Business Practice Location Address
First Line	:	2801 S SAN PEDRO ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90011-2023
Country	:	US
Telephone Number	:	323-233-3100
Fax Number	:	323-233-4100

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/05/2012
Last Update Date	:	07/14/2021

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