Provider Demographics
NPI:1982688990
Name:GITLIN, GRAHAM (MD)
Entity Type:Individual
Prefix:DR
First Name:GRAHAM
Middle Name:
Last Name:GITLIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 MARINE ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-6041
Mailing Address - Country:US
Mailing Address - Phone:310-785-6614
Mailing Address - Fax:310-785-6631
Practice Address - Street 1:2080 CENTURY PARK E STE 809
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90067-2011
Practice Address - Country:US
Practice Address - Phone:310-785-6614
Practice Address - Fax:310-785-6631
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-02
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA63525174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA63525Medicare PIN
CAH60453Medicare UPIN