Provider Demographics
NPI:1104096239
Name:PITARAS, ELIAS (MD)
Entity type:Individual
Prefix:DR
First Name:ELIAS
Middle Name:
Last Name:PITARAS
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 1:1029 MEDICAL CENTER CIR
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42066-1189
Mailing Address - Country:US
Mailing Address - Phone:270-251-4141
Mailing Address - Fax:270-251-4522
Practice Address - Street 1:1029 MEDICAL CENTER CIR
Practice Address - Street 2:
Practice Address - City:MAYFIELD
Practice Address - State:KY
Practice Address - Zip Code:42066-1189
Practice Address - Country:US
Practice Address - Phone:270-251-4141
Practice Address - Fax:270-251-4522
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-04
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY41409207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100043080Medicaid
KY00642001Medicare PIN