Provider Demographics
NPI:1578835021
Name:JONATHAN J TYE, MD A PROFESSIONAL CORP
Entity Type:Organization
Organization Name:JONATHAN J TYE, MD A PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TYE
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACC
Authorized Official - Phone:626-960-6588
Mailing Address - Street 1:1250 S SUNSET AVE
Mailing Address - Street 2:STE 202
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-3961
Mailing Address - Country:US
Mailing Address - Phone:626-960-6588
Mailing Address - Fax:626-338-0688
Practice Address - Street 1:1250 S SUNSET AVE
Practice Address - Street 2:STE 202
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3961
Practice Address - Country:US
Practice Address - Phone:626-960-6588
Practice Address - Fax:626-338-0688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-30
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA44747207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FT604AOtherMEDICARE ORGANIZATION PTAN
110182967OtherRAILROAD MEDICARE
CA00A447470Medicaid
CA00A447470Medicaid
110182967OtherRAILROAD MEDICARE