Provider Demographics
NPI:1336516277
Name:GHIAM, JONATHAN (DO)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:GHIAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10501 WILSHIRE BLVD UNIT 1411
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-6314
Mailing Address - Country:US
Mailing Address - Phone:213-748-2411
Mailing Address - Fax:
Practice Address - Street 1:1401 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015
Practice Address - Country:US
Practice Address - Phone:772-398-7936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-26
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A16421207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty