Provider Demographics
NPI:1255619789
Name:MAN, JONATHAN PAUL (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:PAUL
Last Name:MAN
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 1:10470 OLD PLACERVILLE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:2800 L ST FL 6
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5616
Practice Address - Country:US
Practice Address - Phone:916-887-4040
Practice Address - Fax:916-887-4045
Is Sole Proprietor?:No
Enumeration Date:2011-08-02
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT200414390200000X, 207RC0001X
CAC159950207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ871559Medicaid
AZZ165682Medicare PIN