Provider Demographics
NPI:1790754679
Name:LOM, JITKA (MD)
Entity Type:Individual
Prefix:DR
First Name:JITKA
Middle Name:
Last Name:LOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:280 PALE SAN VITORES RD
Mailing Address - Street 2:
Mailing Address - City:TAMUNING
Mailing Address - State:GU
Mailing Address - Zip Code:96913-3615
Mailing Address - Country:US
Mailing Address - Phone:671-647-4542
Mailing Address - Fax:671-647-4558
Practice Address - Street 1:280 PALE SAN VITORES RD
Practice Address - Street 2:
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913-3615
Practice Address - Country:US
Practice Address - Phone:671-647-4542
Practice Address - Fax:671-647-4558
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GUMOO1288207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G67594Medicare UPIN