Provider Demographics
NPI:1205171485
Name:JESITUS, DAVID
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:JESITUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:739 WALAVISTA AVENUE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610
Mailing Address - Country:US
Mailing Address - Phone:415-571-5123
Mailing Address - Fax:
Practice Address - Street 1:2100 WEBSTER ST STE 225
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-2376
Practice Address - Country:US
Practice Address - Phone:415-923-3012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-29
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57039183500000X
OH03318325183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist