Provider Demographics
NPI:1003830118
Name:PRINCE, JONATHAN ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:ANDREW
Last Name:PRINCE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 660640
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91066-0640
Mailing Address - Country:US
Mailing Address - Phone:626-447-0296
Mailing Address - Fax:626-447-6057
Practice Address - Street 1:18321 CLARK ST
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3501
Practice Address - Country:US
Practice Address - Phone:818-708-5170
Practice Address - Fax:818-705-2595
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA90191207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A901910Medicaid
CA00A901910Medicaid
CAWA90191AMedicare PIN
CAWA90191BMedicare PIN