Provider Demographics
NPI:1043469901
Name:FIDANI, JONATHAN
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:
Last Name:FIDANI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1143 E JUANITA AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-6106
Mailing Address - Country:US
Mailing Address - Phone:626-857-7755
Mailing Address - Fax:
Practice Address - Street 1:205 PASADENA AVE
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-2919
Practice Address - Country:US
Practice Address - Phone:323-344-5541
Practice Address - Fax:323-344-5550
Is Sole Proprietor?:No
Enumeration Date:2008-09-16
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7708OtherMEDICAL
CA7184OtherMEDICAL
CA7667OtherMEDICAL
CA7368OtherMEDICAL