Provider Demographics
NPI:1053500926
Name:JITKA CIVRNA
Entity Type:Organization
Organization Name:JITKA CIVRNA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JITKA
Authorized Official - Middle Name:
Authorized Official - Last Name:CIVRNA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-773-4948
Mailing Address - Street 1:74-000 COUNTRY CLUB DR. #G2
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260
Mailing Address - Country:US
Mailing Address - Phone:760-773-4948
Mailing Address - Fax:760-773-4910
Practice Address - Street 1:74000 COUNTRY CLUB DR STE G2
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260
Practice Address - Country:US
Practice Address - Phone:760-773-4948
Practice Address - Fax:760-773-4910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ01287ZMedicare PIN