Provider Demographics
NPI:1619978731
Name:ITANI, BILAL (MD)
Entity Type:Individual
Prefix:DR
First Name:BILAL
Middle Name:
Last Name:ITANI
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 1:233 S MINERAL ST
Mailing Address - Street 2:
Mailing Address - City:KEYSER
Mailing Address - State:WV
Mailing Address - Zip Code:26726-2643
Mailing Address - Country:US
Mailing Address - Phone:304-788-0202
Mailing Address - Fax:304-788-4377
Practice Address - Street 1:233 S MINERAL ST
Practice Address - Street 2:
Practice Address - City:KEYSER
Practice Address - State:WV
Practice Address - Zip Code:26726-2643
Practice Address - Country:US
Practice Address - Phone:304-788-0202
Practice Address - Fax:304-788-4377
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2017-01-24
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-04-11
Provider Licenses
StateLicense IDTaxonomies
WV16425208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0043316000Medicaid
WVF59432Medicare UPIN