Provider Demographics
NPI:1417961186
Name:DITLOVE, JACK (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:DITLOVE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N ROBERTSON BLVD STE 501
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-1770
Mailing Address - Country:US
Mailing Address - Phone:310-274-0200
Mailing Address - Fax:310-274-0204
Practice Address - Street 1:250 N ROBERTSON BLVD STE 501
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-1770
Practice Address - Country:US
Practice Address - Phone:310-274-0200
Practice Address - Fax:310-274-0204
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG25418207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A42659Medicare UPIN