Provider Demographics
NPI:1215962642
Name:LETAFATI, ATAOLLAH (MD, FACC, FASE)
Entity type:Individual
Prefix:DR
First Name:ATAOLLAH
Middle Name:
Last Name:LETAFATI
Suffix:
Gender:M
Credentials:MD, FACC, FASE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CAMPUS AVENUE
Mailing Address - Street 2:SUITE #102 MEDICAL OFFICE BUILDING
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240
Mailing Address - Country:US
Mailing Address - Phone:207-777-4080
Mailing Address - Fax:207-777-8903
Practice Address - Street 1:100 CAMPUS AVENUE
Practice Address - Street 2:SUITE #102 MEDICAL OFFICE BUILDING
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240
Practice Address - Country:US
Practice Address - Phone:207-777-4080
Practice Address - Fax:207-777-8903
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME8964ME207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME108370000Medicaid
079553Medicare PIN
B86843Medicare UPIN