Provider Demographics
NPI:1811415631
Name:YOUSSEFZADEH, JONATHAN (DO)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:YOUSSEFZADEH
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 1:9401 ALCOTT ST APT 202
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-3163
Mailing Address - Country:US
Mailing Address - Phone:310-402-3917
Mailing Address - Fax:
Practice Address - Street 1:817 S MAIN ST STE D
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-3407
Practice Address - Country:US
Practice Address - Phone:310-402-3917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-31
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16681207Q00000X
261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine