MEDICARE: DR. JAN A VITEK PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY18295	CA

General Provider Information

NPI Number	:	1699767582
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAN A VITEK PH.D.

Provider Business Mailing Address
First Line	:	445 BELLEVUE AVE
Second Line	:	SUITE 203
City	:	OAKLAND
State	:	CA
Zip	:	94610-4923
Country	:	US
Telephone Number	:	510-381-3090
Fax Number	:	510-835-1405

Provider Business Practice Location Address
First Line	:	445 BELLEVUE AVE
Second Line	:	SUITE 203
City	:	OAKLAND
State	:	CA
Zip	:	94610-4923
Country	:	US
Telephone Number	:	510-381-3090
Fax Number	:	510-835-1405

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/17/2005
Last Update Date	:	10/27/2011

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