Provider Demographics
NPI:1730537838
Name:DIAZ, JONATHAN (PTA)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:DIAZ
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8730 SANTA MONICA BLVD STE G
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90069-4547
Mailing Address - Country:US
Mailing Address - Phone:310-659-2740
Mailing Address - Fax:310-959-2748
Practice Address - Street 1:8730 SANTA MONICA BLVD STE G
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90069-4547
Practice Address - Country:US
Practice Address - Phone:310-659-2740
Practice Address - Fax:310-959-2748
Is Sole Proprietor?:No
Enumeration Date:2016-05-30
Last Update Date:2016-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPTA47990225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant