Provider Demographics
NPI:1699747899
Name:MAITEH, MAMON Y (MD)
Entity type:Individual
Prefix:DR
First Name:MAMON
Middle Name:Y
Last Name:MAITEH
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 1:4235 SECOR RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623
Mailing Address - Country:US
Mailing Address - Phone:419-473-3561
Mailing Address - Fax:
Practice Address - Street 1:4235 SECOR RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-4231
Practice Address - Country:US
Practice Address - Phone:419-479-5560
Practice Address - Fax:419-473-2065
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301079222208000000X
MO20070016242084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4746015Medicaid
MIH74588Medicare UPIN
MI4746015Medicaid
MIN11220042Medicare PIN