Provider Demographics
NPI:1124289806
Name:THEETHAYE L. ITTIARA, M.D., P.C.
Entity type:Organization
Organization Name:THEETHAYE L. ITTIARA, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THEETHAYE
Authorized Official - Middle Name:L
Authorized Official - Last Name:ITTIARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-263-5810
Mailing Address - Street 1:142 E MAUMEE ST
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-2735
Mailing Address - Country:US
Mailing Address - Phone:517-263-5810
Mailing Address - Fax:517-263-5810
Practice Address - Street 1:142 E MAUMEE ST
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-2735
Practice Address - Country:US
Practice Address - Phone:517-263-5810
Practice Address - Fax:517-263-5810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-24
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITI031889251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIA77014Medicare UPIN