Provider Demographics
NPI:1700397338
Name:KITAKA, IVAN ELIJAH (DR)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:ELIJAH
Last Name:KITAKA
Suffix:
Gender:M
Credentials:DR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5720 MONTCLAIR HILL LN
Mailing Address - Street 2:
Mailing Address - City:ROSHARON
Mailing Address - State:TX
Mailing Address - Zip Code:77583-2032
Mailing Address - Country:US
Mailing Address - Phone:713-363-3661
Mailing Address - Fax:
Practice Address - Street 1:11900 BARRYKNOLL LN APT 6109
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77024-4388
Practice Address - Country:US
Practice Address - Phone:832-934-7998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-23
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX60548183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist