MEDICARE: JONATHAN HERNANDEZ DIAZ

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	224P00000X	Prosthetist

General Provider Information

NPI Number	:	1093640708
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN HERNANDEZ DIAZ

Provider Business Mailing Address
First Line	:	1835 S REDONDO BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90019-5363
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11301 WILSHIRE BLVD BLDG 304
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90073-1003
Country	:	US
Telephone Number	:	310-478-3711
Fax Number	:

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

Provider Enumeration Date	:	06/15/2026
Last Update Date	:	06/15/2026

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