1235933466 NPI number — DR. MATHEW ROGIN ITTEERA MD

Table of content: DR. MATHEW ROGIN ITTEERA MD (NPI 1235933466)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235933466 NPI number — DR. MATHEW ROGIN ITTEERA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ITTEERA
Provider First Name:
MATHEW
Provider Middle Name:
ROGIN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1235933466
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/15/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7333 GRAND AVE APT 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOWNERS GROVE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60516-4115
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-234-4439
Provider Business Mailing Address Fax Number:
208-203-1015

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
169 RIVERSIDE DRIVE
Provider Second Line Business Practice Location Address:
GME OFFICES
Provider Business Practice Location Address City Name:
BINGHAMTON
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-722-2769
Provider Business Practice Location Address Fax Number:
607-798-5069
Provider Enumeration Date:
04/04/2025

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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