Provider Demographics
NPI:1346415478
Name:HETTITANTRI, DEEPANI (MD)
Entity Type:Individual
Prefix:
First Name:DEEPANI
Middle Name:
Last Name:HETTITANTRI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MAHAMARAKKALA
Other - Middle Name:PATABANDIGE DEEPANI
Other - Last Name:DIAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:711C E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PURCELLVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20132-3178
Mailing Address - Country:US
Mailing Address - Phone:540-338-7116
Mailing Address - Fax:540-338-6671
Practice Address - Street 1:711C E MAIN ST
Practice Address - Street 2:
Practice Address - City:PURCELLVILLE
Practice Address - State:VA
Practice Address - Zip Code:20132-3178
Practice Address - Country:US
Practice Address - Phone:540-338-7116
Practice Address - Fax:540-338-6671
Is Sole Proprietor?:No
Enumeration Date:2008-04-29
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101246449207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1346415478Medicaid
VA1346415478Medicare UPIN