Provider Demographics
NPI:1821057035
Name:CIVRNA, JITKA (MD)
Entity Type:Individual
Prefix:DR
First Name:JITKA
Middle Name:
Last Name:CIVRNA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74000 COUNTRY CLUB DR G2
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260-1685
Mailing Address - Country:US
Mailing Address - Phone:760-773-4948
Mailing Address - Fax:760-773-4910
Practice Address - Street 1:74000 COUNTRY CLUB DR G2
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260
Practice Address - Country:US
Practice Address - Phone:760-773-4948
Practice Address - Fax:760-773-4910
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50201207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA861119983OtherTIN
CAF76266Medicare UPIN
CA861119983OtherTIN
CA00A502012Medicare PIN