Provider Demographics
NPI:1750512489
Name:JONATHAN AHDOOT MD INC
Entity type:Organization
Organization Name:JONATHAN AHDOOT MD INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:AHDOOT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-727-4330
Mailing Address - Street 1:15775 LAGUNA CANYON RD
Mailing Address - Street 2:SUITE 290
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-3145
Mailing Address - Country:US
Mailing Address - Phone:949-727-4330
Mailing Address - Fax:949-727-1851
Practice Address - Street 1:15775 LAGUNA CANYON RD
Practice Address - Street 2:SUITE 290
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3145
Practice Address - Country:US
Practice Address - Phone:949-727-4330
Practice Address - Fax:949-727-1851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-29
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA44025207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A440250Medicaid