Provider Demographics
NPI:1316388556
Name:ITIDIARE, MICHAEL (DO, MBS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:ITIDIARE
Suffix:
Gender:M
Credentials:DO, MBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1445 WHITEHORSE MERCERVILLE RD STE 108
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08619-3834
Mailing Address - Country:US
Mailing Address - Phone:609-528-8884
Mailing Address - Fax:
Practice Address - Street 1:1445 WHITEHORSE MERCERVILLE RD STE 108
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:NJ
Practice Address - Zip Code:08619-3834
Practice Address - Country:US
Practice Address - Phone:609-528-8884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-16
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB10130600207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology