1710966593 NPI number — JACK WARREN ITO PHD

Table of content: JACK WARREN ITO PHD (NPI 1710966593)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710966593 NPI number — JACK WARREN ITO PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ITO
Provider First Name:
JACK
Provider Middle Name:
WARREN
Provider Name Prefix Text:
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:
MARTIN
Provider Other First Name:
TODD
Provider Other Middle Name:
WARREN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1710966593
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/01/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 63
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
29 PALMS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92277
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-830-2782
Provider Business Mailing Address Fax Number:
724-407-1201

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
NAVAL HOSPITAL 29 PALMS
Provider Second Line Business Practice Location Address:
MCAGCC
Provider Business Practice Location Address City Name:
29 PALMS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92278
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-830-2782
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/11/2006

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: 103TC0700X , with the licence number:  PS008530L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103T00000X , with the licence number: PS008530L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 016536380004 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 163751 . This is a "VALUE BEHAVIORAL HEALTH" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 959098 . This is a "HIGHMARK PROVIDER NUMBER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: A771081 . This is a "VALUE BEHAVIORAL HEALTH" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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