Provider Demographics
NPI:1174184386
Name:MAW, JONATHAN (DO)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:MAW
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 WALNUT ST APT 4F
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-6160
Mailing Address - Country:US
Mailing Address - Phone:201-406-5750
Mailing Address - Fax:
Practice Address - Street 1:1500 SAN PABLO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5313
Practice Address - Country:US
Practice Address - Phone:323-442-2553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-27
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT0194992085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology