Provider Demographics
NPI:1376120147
Name:LITVAK, JONATHAN
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:LITVAK
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 1:9022 LAMAR ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91977-2756
Mailing Address - Country:US
Mailing Address - Phone:623-219-0555
Mailing Address - Fax:
Practice Address - Street 1:9022 LAMAR ST UNIT A
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91977
Practice Address - Country:US
Practice Address - Phone:623-219-0555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-26
Last Update Date:2021-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program