Provider Demographics
NPI:1447360086
Name:CORREN, JONATHAN (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:CORREN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10780 SANTA MONICA BLVD. STE 280
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-4749
Mailing Address - Country:US
Mailing Address - Phone:310-312-5050
Mailing Address - Fax:310-575-9292
Practice Address - Street 1:10780 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 280
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-4749
Practice Address - Country:US
Practice Address - Phone:310-312-5050
Practice Address - Fax:310-575-9292
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG53016207KI0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KI0005XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyClinical & Laboratory Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG53016OtherLICENSE
CAZZZ73295ZOtherBLUE SHIELD
CAZZZ73295ZOtherBLUE SHIELD
CAE67600Medicare UPIN