Provider Demographics
NPI:1992903710
Name:JITTIMA JIRASETPATANA
Entity type:Organization
Organization Name:JITTIMA JIRASETPATANA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JITTIMA
Authorized Official - Middle Name:
Authorized Official - Last Name:JIRASETPATANA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:818-242-3668
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:91204-2500
Practice Address - Country:US
Practice Address - Phone:818-242-3668
Practice Address - Fax:818-242-2425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-03
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4442213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5199210001Medicare NSC
CAY07189Medicare UPIN
CAWE4442BMedicare ID - Type Unspecified
CAW17189Medicare PIN