Provider Demographics
NPI:1922186402
Name:ALLEN, JONATHAN WALTER (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:WALTER
Last Name:ALLEN
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 1:2500 MERCED STREET
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-4201
Mailing Address - Country:US
Mailing Address - Phone:510-454-1000
Mailing Address - Fax:
Practice Address - Street 1:2500 MERCED STREET
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-4201
Practice Address - Country:US
Practice Address - Phone:510-454-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY175607207RC0000X
CAG76225207RC0000X
AZ69326207RC0000X
WAIMLC.MD.61407700207RC0000X
CODR.00698522207RC0000X
OK41042207RC0000X
GA94746207RC0000X
NC2023-01015207RC0000X
SC89343207RC0000X
HIMD-13915207RC0000X
FLTPME4726207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
F63471Medicare UPIN
00G762250Medicare ID - Type Unspecified