Provider Demographics
NPI:1225287246
Name:DE, JITA (MD)
Entity Type:Individual
Prefix:
First Name:JITA
Middle Name:
Last Name:DE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2973 HARBOR BLVD # 148
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-3912
Mailing Address - Country:US
Mailing Address - Phone:713-480-3159
Mailing Address - Fax:
Practice Address - Street 1:7205 ALMEDA RD # 30246
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054-2191
Practice Address - Country:US
Practice Address - Phone:713-480-3159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-15
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0015106207ZC0006X, 207ZH0000X
TN47658207ZH0000X
VA0101249886207ZH0000X
MI4301089334207ZH0000X
CAM9957207ZP0102X
TXM9957282N00000X
CAA110924207ZH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
No207ZC0006XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No282N00000XHospitalsGeneral Acute Care Hospital