Provider Demographics
NPI:1073627600
Name:TULATHIMUTTE, ROENGSAK (MD)
Entity Type:Individual
Prefix:
First Name:ROENGSAK
Middle Name:
Last Name:TULATHIMUTTE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 S SYCAMORE KNLS
Mailing Address - Street 2:
Mailing Address - City:SOUTH HADLEY
Mailing Address - State:MA
Mailing Address - Zip Code:01075-1112
Mailing Address - Country:US
Mailing Address - Phone:413-534-8985
Mailing Address - Fax:
Practice Address - Street 1:575 BEECH ST
Practice Address - Street 2:ANESTHESIA DEPT
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-2223
Practice Address - Country:US
Practice Address - Phone:413-534-2845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA47834207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAHX4518OtherMEDICARE ID