Provider Demographics
NPI:1659347904
Name:SEGAL, ITA S (MD)
Entity Type:Individual
Prefix:
First Name:ITA
Middle Name:S
Last Name:SEGAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:630 PLANTATION ST
Mailing Address - Street 2:WOT 12TH FLOOR ATTN PHYSICIAN SERVICES
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605
Mailing Address - Country:US
Mailing Address - Phone:508-368-5529
Mailing Address - Fax:508-368-5530
Practice Address - Street 1:135 GOLD STAR BLVD
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01606
Practice Address - Country:US
Practice Address - Phone:508-853-2716
Practice Address - Fax:508-856-9025
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT0307172085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AA39601OtherHARVARD PILGRIM HEALTHCAR
042472266OtherONE HEALTH PLAN
042472266OtherPRIVATE HEALTHCARE SYSTEM
2110458OtherWELFARE
77954OtherFALLON COMMUNITY HEALTH P
MA2110458Medicaid
347461OtherTUFTS HEALTH PLAN
J29502OtherBLUE CARE ELECT
786705OtherMVP HEALTH CARE
MA2110458Medicaid