Provider Demographics
NPI:1720095185
Name:CITRO, DOUGLAS D (PHD)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:D
Last Name:CITRO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17782 COWAN
Mailing Address - Street 2:STE A
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-6041
Mailing Address - Country:US
Mailing Address - Phone:714-290-1770
Mailing Address - Fax:949-208-6981
Practice Address - Street 1:17782 COWAN
Practice Address - Street 2:STE A
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-6041
Practice Address - Country:US
Practice Address - Phone:714-290-1770
Practice Address - Fax:949-208-6981
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY202312103T00000X
CACP8510103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY085100Medicaid
CA00PL851000OtherBLUE SHIELD
CACP8510Medicare ID - Type Unspecified