Provider Demographics
NPI:1114021789
Name:JIRASETPATANA, JITTIMA (DPM)
Entity type:Individual
Prefix:
First Name:JITTIMA
Middle Name:
Last Name:JIRASETPATANA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 S CENTRAL AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2576
Mailing Address - Country:US
Mailing Address - Phone:818-242-3668
Mailing Address - Fax:818-242-2425
Practice Address - Street 1:1510 S CENTRAL AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2577
Practice Address - Country:US
Practice Address - Phone:818-242-3668
Practice Address - Fax:818-242-2425
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4442213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
Y07189Medicare UPIN
WE4442BMedicare ID - Type Unspecified