Provider Demographics
NPI:1447232855
Name:LETTRICK, MICHAEL ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ALLEN
Last Name:LETTRICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3 BLUE MOUNTAIN TRL
Mailing Address - Street 2:
Mailing Address - City:EAST GREENBUSH
Mailing Address - State:NY
Mailing Address - Zip Code:12061-2401
Mailing Address - Country:US
Mailing Address - Phone:518-477-1191
Mailing Address - Fax:518-477-1255
Practice Address - Street 1:1528 COLUMBIA TPKE
Practice Address - Street 2:
Practice Address - City:CASTLETON
Practice Address - State:NY
Practice Address - Zip Code:12033-9584
Practice Address - Country:US
Practice Address - Phone:518-477-1191
Practice Address - Fax:518-477-1255
Is Sole Proprietor?:No
Enumeration Date:2005-11-19
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY189372207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01699403Medicaid
NYF42903Medicare UPIN
NYCC4979Medicare ID - Type Unspecified