Provider Demographics
NPI:1497717292
Name:LITVINOFF, JEROME SAMUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:SAMUEL
Last Name:LITVINOFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6536 CRYSTALAIRE DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-3902
Mailing Address - Country:US
Mailing Address - Phone:619-583-1200
Mailing Address - Fax:619-583-8903
Practice Address - Street 1:6536 CRYSTALAIRE DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-3902
Practice Address - Country:US
Practice Address - Phone:619-583-1200
Practice Address - Fax:619-583-8903
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG20193207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G201930Medicaid
A90628Medicare UPIN
CA00G201930Medicaid