1720095185 NPI number — MR. DOUGLAS D CITRO PHD

Table of content: MR. DOUGLAS D CITRO PHD (NPI 1720095185)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720095185 NPI number — MR. DOUGLAS D CITRO PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CITRO
Provider First Name:
DOUGLAS
Provider Middle Name:
D
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720095185
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/15/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17782 COWAN
Provider Second Line Business Mailing Address:
STE A
Provider Business Mailing Address City Name:
IRVINE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92614-6041
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-290-1770
Provider Business Mailing Address Fax Number:
949-208-6981

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17782 COWAN
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
IRVINE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92614-6041
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-290-1770
Provider Business Practice Location Address Fax Number:
949-208-6981
Provider Enumeration Date:
08/01/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  PSY202312 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X , with the licence number: CP8510 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PSY085100 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00PL851000 . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".