Provider Demographics
NPI:1417982646
Name:TALLMAN, JONATHAN B (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:B
Last Name:TALLMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 EMELINE AVE
Mailing Address - Street 2:1080 EMELINE AVE.
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-1976
Mailing Address - Country:US
Mailing Address - Phone:831-454-4170
Mailing Address - Fax:831-454-4663
Practice Address - Street 1:12 W BEACH ST
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-4504
Practice Address - Country:US
Practice Address - Phone:831-763-8990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA693362084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ91892ZOtherMEDICARE GROUP ID#
CAZZZ92073ZOtherMEDICARE GROUP ID#
CAZZZ91891ZOtherMEDICARE GROUP ID#
CAZZZ92069ZOtherMEDICARE GROUP ID#
CA00A693360Medicaid
CAA69336OtherMEDICAL LICENSE #
CAA69336OtherMEDICAL LICENSE #
CAZZZ92073ZOtherMEDICARE GROUP ID#
CAG97873Medicare UPIN