Healthcare Provider Details

I. General information

NPI: 1861605362
Provider Name (Legal Business Name): CRISTINA TITA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 06/22/2020
Certification Date: 06/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 E MICHIGAN AVE STE 100
JACKSON MI
49201-1800
US

IV. Provider business mailing address

2799 W GRAND BLVD DEPT OF CARDIOLOGY
DETROIT MI
48202-2608
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-3345
  • Fax:
Mailing address:
  • Phone: 313-916-2966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301082141
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number4301082141
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207RA0001X
TaxonomyAdvanced Heart Failure and Transplant Cardiology Physician
License Number4301082141
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: