Healthcare Provider Details

I. General information

NPI: 1972289379
Provider Name (Legal Business Name): HUTHAIFA MUTHANNA KETTANA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2023
Last Update Date: 07/24/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 S. STATE ST
DOVER DE
19901
US

IV. Provider business mailing address

4 GRAND HALL HARROW DRIVE
DOVER DE
19904
US

V. Phone/Fax

Practice location:
  • Phone: 302-674-4700
  • Fax:
Mailing address:
  • Phone: 442-322-7805
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC7-0018348
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: