1174585475 NPI number — DR. THEETHAYE LONAPPAN ITTIARA M.D

Table of content: (NPI 1083192587)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174585475 NPI number — DR. THEETHAYE LONAPPAN ITTIARA M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ITTIARA
Provider First Name:
THEETHAYE
Provider Middle Name:
LONAPPAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174585475
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5442 PINE VIEW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YPSILANTI
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48197-8963
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-485-0868
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
142 E MAUMEE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ADRIAN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49221-2735
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-263-5810
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  4301031889 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com