Provider Demographics
NPI:1396913695
Name:JONATHAN M. DAVIDORF, M.D. INC.
Entity type:Organization
Organization Name:JONATHAN M. DAVIDORF, M.D. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:DAVIDORF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-883-0112
Mailing Address - Street 1:7320 WOODLAKE AVE
Mailing Address - Street 2:SUITE 190
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91307-1468
Mailing Address - Country:US
Mailing Address - Phone:818-883-0112
Mailing Address - Fax:
Practice Address - Street 1:7320 WOODLAKE AVE
Practice Address - Street 2:SUITE 190
Practice Address - City:WEST HILLS
Practice Address - State:CA
Practice Address - Zip Code:91307-1468
Practice Address - Country:US
Practice Address - Phone:818-883-0112
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW21967Medicare PIN