Provider Demographics
NPI:1629005814
Name:PRIVITERA, MICHAEL D (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:PRIVITERA
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:PO BOX 636256 CENTRAL CREDENTIALING
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0001
Mailing Address - Country:US
Mailing Address - Phone:513-585-5504
Mailing Address - Fax:513-585-5511
Practice Address - Street 1:3113 BELLEVUE AVE FL 3
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-3158
Practice Address - Country:US
Practice Address - Phone:513-652-6500
Practice Address - Fax:513-475-8033
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350544942084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0645403Medicaid
OH130010777OtherMEDICARE RAILROAD
OH130010777OtherMEDICARE RAILROAD
OH0645403Medicaid