Provider Demographics
NPI:1609973882
Name:JONATHAN NORDLICHT MD MEDICAL CORPORATION
Entity Type:Organization
Organization Name:JONATHAN NORDLICHT MD MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF CORPORATION
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:FRANK
Authorized Official - Last Name:NORDLICHT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-668-5666
Mailing Address - Street 1:3905 SACRAMENTO
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94118
Mailing Address - Country:US
Mailing Address - Phone:415-668-5666
Mailing Address - Fax:415-668-5866
Practice Address - Street 1:3905 SACRAMENTO
Practice Address - Street 2:SUITE 104
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94118
Practice Address - Country:US
Practice Address - Phone:415-668-5666
Practice Address - Fax:415-668-5866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG32963207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G32963Medicare PIN