Healthcare Provider Details

I. General information

NPI: 1447232855
Provider Name (Legal Business Name): MICHAEL ALLEN LETTRICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2005
Last Update Date: 06/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1528 COLUMBIA TPKE
CASTLETON NY
12033-9584
US

IV. Provider business mailing address

3 BLUE MOUNTAIN TRL
EAST GREENBUSH NY
12061-2401
US

V. Phone/Fax

Practice location:
  • Phone: 518-477-1191
  • Fax: 518-477-1255
Mailing address:
  • Phone: 518-477-1191
  • Fax: 518-477-1255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number189372
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: