Basic Information
| Provider Information | |||||||||
| NPI: | 1063621209 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TOLENTINO | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1120 NW 14TH ST # ST960 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331362107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052434258 | ||||||||
| FaxNumber: | 3052437096 | ||||||||
| Practice Location | |||||||||
| Address1: | 1150 NW 14TH ST STE 411 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331362137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052434900 | ||||||||
| FaxNumber: | 3052434966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 10/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME143438 | FL | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | ME143438 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3039278 | 05 | OH | MEDICAID | 200988420 | 05 | IN | MEDICAID | 7100112680 | 05 | KY | MEDICAID |