Provider Demographics
NPI:1831204627
Name:WANAGAT, JONATHAN (MD PHD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:WANAGAT
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD
Mailing Address - Street 2:200
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:310-206-7272
Mailing Address - Fax:310-794-2113
Practice Address - Street 1:200 MEDICAL PLZ
Practice Address - Street 2:SUITE 420
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-0001
Practice Address - Country:US
Practice Address - Phone:310-206-2583
Practice Address - Fax:310-794-2199
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA107495207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1831204627Medicaid
CABX271ZMedicare PIN