Provider Demographics
NPI:1912929670
Name:HIATT, JONATHAN R (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:R
Last Name:HIATT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5632
Mailing Address - Country:US
Mailing Address - Phone:310-794-7066
Mailing Address - Fax:310-825-0189
Practice Address - Street 1:10833 LE CONTE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095
Practice Address - Country:US
Practice Address - Phone:310-206-3748
Practice Address - Fax:310-825-0189
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG37809204F00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G378090Medicaid
CAWG37809JMedicare PIN
CAA47237Medicare UPIN
CA00G378090Medicaid