Provider Demographics
NPI:1396038477
Name:SKUPSKY, JONATHAN (MD/PHD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:SKUPSKY
Suffix:
Gender:M
Credentials:MD/PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 CITY BLVD W
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-2903
Mailing Address - Country:US
Mailing Address - Phone:714-456-7890
Mailing Address - Fax:
Practice Address - Street 1:333 CITY BLVD W
Practice Address - Street 2:SUITE 400
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868
Practice Address - Country:US
Practice Address - Phone:714-456-7890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-23
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA124805207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology