Healthcare Provider Details

I. General information

NPI: 1821127838
Provider Name (Legal Business Name): JASON GITTER R.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 10/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19360 MOUNTAIN MDW N
HIDDEN VALLEY LAKE CA
95467-8540
US

IV. Provider business mailing address

19360 MOUNTAIN MDW N
HIDDEN VALLEY LAKE CA
95467-8540
US

V. Phone/Fax

Practice location:
  • Phone: 707-671-4231
  • Fax:
Mailing address:
  • Phone: 707-671-4231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number862449
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: