Provider Demographics
NPI:1255469599
Name:GITTMAN, JASON E (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:E
Last Name:GITTMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12440 N 40TH DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-2969
Mailing Address - Country:US
Mailing Address - Phone:602-588-7007
Mailing Address - Fax:
Practice Address - Street 1:11045 N 19TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-4816
Practice Address - Country:US
Practice Address - Phone:623-849-1869
Practice Address - Fax:623-849-5880
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10754207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ152056OtherMEDICARE PTAN