Healthcare Provider Details

I. General information

NPI: 1871829069
Provider Name (Legal Business Name): BRYANT T ITTIARA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2009
Last Update Date: 01/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18707 ECORSE RD
ALLEN PARK MI
48101-2255
US

IV. Provider business mailing address

416 JAMES CIR
ROYAL OAK MI
48067-4545
US

V. Phone/Fax

Practice location:
  • Phone: 734-682-3309
  • Fax: 734-682-1488
Mailing address:
  • Phone: 734-604-0017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberL1593593
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number5101017919
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number5101017919
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: