Provider Demographics
NPI:1114087160
Name:HARETOS, JOHN THEODORE (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:THEODORE
Last Name:HARETOS
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 1:160 N CRAIG ST
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15213-2716
Mailing Address - Country:US
Mailing Address - Phone:412-621-3431
Mailing Address - Fax:412-621-0878
Practice Address - Street 1:160 N CRAIG ST
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15213-2716
Practice Address - Country:US
Practice Address - Phone:412-621-3431
Practice Address - Fax:412-621-0878
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD028204E207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0001006134Medicaid
PAC31451Medicare UPIN
PA0001006134Medicaid