Provider Demographics
NPI:1568588622
Name:EITEL, JENNIFER M (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:EITEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6611 CEDARWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-6659
Mailing Address - Country:US
Mailing Address - Phone:714-308-6784
Mailing Address - Fax:
Practice Address - Street 1:6611 CEDARWOOD DR
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-6659
Practice Address - Country:US
Practice Address - Phone:714-308-6784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN1711208000000X
CAA104530208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX198795002Medicaid
TX198795003Medicaid
NVLL1716OtherMEDICAL LICENSE
TX198795005Medicaid
TX198795011Medicaid
TX198795001Medicaid
TX198795004Medicaid
TX198795006Medicaid
TX198795006Medicaid