1235225921 NPI number — JONDAVID MENTEER MD

Table of content: JONDAVID MENTEER MD (NPI 1235225921)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235225921 NPI number — JONDAVID MENTEER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MENTEER
Provider First Name:
JONDAVID
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235225921
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6430 W SUNSET BLVD
Provider Second Line Business Mailing Address:
SUITE 600
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90028-7901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-361-2461
Provider Business Mailing Address Fax Number:
323-361-1513

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6450 W SUNSET BLVD
Provider Second Line Business Practice Location Address:
MS# 34
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90028-7315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-361-2461
Provider Business Practice Location Address Fax Number:
323-361-1513
Provider Enumeration Date:
10/04/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2080P0202X , with the licence number:  A86946 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00A869460 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00A869460 F98 . This is a "CAL OPTIMA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".