Provider Demographics
NPI:1538119953
Name:TIRITILLI, MARK E
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:TIRITILLI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 ESKENAZI AVE
Mailing Address - Street 2:FIFTH THIRD BANK BLDG, 5TH FL
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-4166
Mailing Address - Country:US
Mailing Address - Phone:317-880-4121
Mailing Address - Fax:317-880-0343
Practice Address - Street 1:9443 E 38TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46235-2132
Practice Address - Country:US
Practice Address - Phone:317-890-2100
Practice Address - Fax:317-890-2171
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01043935A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100200080Medicaid
IN715530VVVVMedicare PIN
IN100200080Medicaid