Provider Demographics
NPI:1104885656
Name:PITTA, KUTUMBA S
Entity type:Individual
Prefix:
First Name:KUTUMBA
Middle Name:S
Last Name:PITTA
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 1:1868 HOOPER AVE
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-8175
Mailing Address - Country:US
Mailing Address - Phone:732-244-6743
Mailing Address - Fax:732-244-6917
Practice Address - Street 1:1868 HOOPER AVE
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753-8175
Practice Address - Country:US
Practice Address - Phone:732-244-6743
Practice Address - Fax:732-244-6917
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-22
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA0753800208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJP421291OtherOXFORD HC
4093719OtherAETNA HC
NJ153300Medicaid
C53177Medicare UPIN
NJ153300Medicaid