Provider Demographics
NPI:1710019559
Name:TIRALLA, JOSEPH R (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:R
Last Name:TIRALLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:110 HOSPITAL RD
Mailing Address - Street 2:SUITE #211
Mailing Address - City:PRINCE FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:20678-4019
Mailing Address - Country:US
Mailing Address - Phone:410-257-3150
Mailing Address - Fax:410-535-6836
Practice Address - Street 1:110 HOSPITAL RD
Practice Address - Street 2:SUITE #202
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-4019
Practice Address - Country:US
Practice Address - Phone:410-257-3150
Practice Address - Fax:410-535-3912
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0020619207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
366483OtherMAMSI UNITED HEALTH CARE
6906-0002OtherBLUE SHIELD DC
2217645OtherAETNA US HEALTHCARE
366030-03OtherBLUE SHIELD OF MARYLAND
366483OtherMAMSI UNITED HEALTH CARE
MD059N906FMedicare ID - Type Unspecified