Provider Demographics
NPI:1386417913
Name:SIMONIAN, JONATHAN CHARLES
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:CHARLES
Last Name:SIMONIAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 SHERWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-3715
Mailing Address - Country:US
Mailing Address - Phone:650-814-7647
Mailing Address - Fax:
Practice Address - Street 1:3D RECON BN
Practice Address - Street 2:UNIT 36180
Practice Address - City:NAGO
Practice Address - State:OKINAWA
Practice Address - Zip Code:96389
Practice Address - Country:JP
Practice Address - Phone:315-625-8008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman