Provider Demographics
NPI:1093977183
Name:ITIN, ROMAN
Entity Type:Individual
Prefix:MR
First Name:ROMAN
Middle Name:
Last Name:ITIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 ZANKER ROAD
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95134-2107
Mailing Address - Country:US
Mailing Address - Phone:408-325-5100
Mailing Address - Fax:
Practice Address - Street 1:2625 ZANKER RD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95134-2130
Practice Address - Country:US
Practice Address - Phone:408-325-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist