Provider Demographics
NPI:1316000805
Name:CIVAN, JESSE MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:MICHAEL
Last Name:CIVAN
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 1:132 SOUTH 10TH STREET
Mailing Address - Street 2:480 MAIN BUILDING
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107
Mailing Address - Country:US
Mailing Address - Phone:215-955-8900
Mailing Address - Fax:215-955-5245
Practice Address - Street 1:132 SOUTH 10TH STREET
Practice Address - Street 2:480 MAIN BUILDING
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107
Practice Address - Country:US
Practice Address - Phone:215-955-8900
Practice Address - Fax:215-955-5245
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD436852207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology