Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207KA0200X | Allergist | A125923 | CA |
N | 208000000X | Pediatrician | 125-052818 | IL |
N | 208000000X | Pediatrician | 54495 | WI |
NPI | 1619133600 |
---|---|
Provider Name | Jonathan Tam |
First Address | Los Angeles, CA 90027-6062 |
Second Address | Los Angeles, CA 90027-6062 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/07/2008 |
Last Update Date | 17/06/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
125-052818 | ILLINOIS LICENSE (01) | IL |