Provider Demographics
NPI:1164590600
Name:TITESWORTH, BRIAN D (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:D
Last Name:TITESWORTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5701 BOW POINTE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-3199
Mailing Address - Country:US
Mailing Address - Phone:248-625-2621
Mailing Address - Fax:248-625-2622
Practice Address - Street 1:834 S LAPEER RD STE 100
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MI
Practice Address - Zip Code:48371-5039
Practice Address - Country:US
Practice Address - Phone:248-384-8320
Practice Address - Fax:248-384-8321
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301076070208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
BT076070OtherCOMMERCIAL-COMMERCIAL NUMBER
700H262220OtherBLUE CROSS-BLUE CROSS
BT076070OtherCHAMPUS-CHAMPUS
MI466146410Medicaid
BT076070OtherCHAMPUS-CHAMPUS
MI466146410Medicaid