Healthcare Provider Details

I. General information

NPI: 1043482912
Provider Name (Legal Business Name): BIJOY DAMODARAN THATTALIYATH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2008
Last Update Date: 08/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HAWKINS DR DEPARTMENT OF PEDIATRICS
IOWA CITY IA
52242-1009
US

IV. Provider business mailing address

200 HAWKINS DR DEPARTMENT OF PEDIATRICS
IOWA CITY IA
52242-1009
US

V. Phone/Fax

Practice location:
  • Phone: 352-219-6107
  • Fax:
Mailing address:
  • Phone: 352-219-6107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberMD-43679
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number2011-01418
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: