Healthcare Provider Details

I. General information

NPI: 1992903710
Provider Name (Legal Business Name): JITTIMA JIRASETPATANA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 05/09/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 S CENTRAL AVE SUITE 120
GLENDALE CA
91204-2500
US

IV. Provider business mailing address

1510 S CENTRAL AVE STE 120
GLENDALE CA
91204-2576
US

V. Phone/Fax

Practice location:
  • Phone: 818-242-3668
  • Fax: 818-242-2425
Mailing address:
  • Phone: 818-242-3668
  • Fax: 818-242-2425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE4442
License Number StateCA

VIII. Authorized Official

Name: JITTIMA JIRASETPATANA
Title or Position: OWNER
Credential: DPM
Phone: 818-242-3668