Healthcare Provider Details

I. General information

NPI: 1558980466
Provider Name (Legal Business Name): JITHIN JOHN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2020
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 GRAND CONCOURSE
BRONX NY
10457-7679
US

IV. Provider business mailing address

1650 GRAND CONCOURSE
BRONX NY
10457-7679
US

V. Phone/Fax

Practice location:
  • Phone: 718-992-7669
  • Fax:
Mailing address:
  • Phone: 718-992-7669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number322288
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: