Provider Demographics
NPI:1801578414
Name:MAO, JONATHAN (DPT)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:MAO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:789 FRESCA DR
Mailing Address - Street 2:
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93030-0163
Mailing Address - Country:US
Mailing Address - Phone:805-815-7689
Mailing Address - Fax:
Practice Address - Street 1:12400 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-2522
Practice Address - Country:US
Practice Address - Phone:310-264-8385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-02
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA304346225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist