Basic Information
| Provider Information | |||||||||
| NPI: | 1740833912 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OLIDEN CORTEZ | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | ALFREDO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | BS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | OLIDEN | ||||||||
| OtherFirstName: | JONATHAN | ||||||||
| OtherMiddleName: | ALFREDO | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | BS | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10205 SAMOA AVE APT 201 | ||||||||
| Address2: | |||||||||
| City: | TUJUNGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910423538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8182939783 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1020 S ARROYO PKWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911053912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264032794 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2019 | ||||||||
| LastUpdateDate: | 07/17/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.