Provider Demographics
NPI:1508070558
Name:USITALO, HOWARD R (MD)
Entity Type:Individual
Prefix:DR
First Name:HOWARD
Middle Name:R
Last Name:USITALO
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 1:3621 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1633
Mailing Address - Country:US
Mailing Address - Phone:734-647-5299
Mailing Address - Fax:
Practice Address - Street 1:14650 E OLD US HIGHWAY 12
Practice Address - Street 2:
Practice Address - City:CHELSEA
Practice Address - State:MI
Practice Address - Zip Code:48118-1801
Practice Address - Country:US
Practice Address - Phone:734-593-4220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301046819208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3408102461OtherBCBS OF MI
MI0H10723OtherBCBSM
MI102705381Medicaid
MI3408102461OtherBCBS OF MI
MI102705381Medicaid
MI0H10723OtherBCBSM