Basic Information
| Provider Information | |||||||||
| NPI: | 1003897117 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ENGELHARDT | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | TODD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 POWELL ST STE 400 | ||||||||
| Address2: | |||||||||
| City: | EMERYVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946081826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103502600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2500 GRANT RD | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN VIEW | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6509407000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 09/30/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 32462 | AZ | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | A89837 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 39-81220 | 01 | AZ | EVERCARE GROUP | OTHER | 453051001 | 01 | AZ | GROUP HEALTH GROUP | OTHER | AZ0728670 | 01 | AZ | BLUECROSS/BLUESHIELD GRP | OTHER | 86-0373636 | 01 | AZ | HUMANA GROUP | OTHER | 884016 | 05 | AZ | MEDICAID | AW1436 | 01 | AZ | HEALTHNET GROUP | OTHER |