Provider Demographics
NPI:1740395169
Name:ANCHETA, PRISCILLA ITLIONG (MD)
Entity Type:Individual
Prefix:DR
First Name:PRISCILLA
Middle Name:ITLIONG
Last Name:ANCHETA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2411 ALLEN BLVD
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-1740
Mailing Address - Country:US
Mailing Address - Phone:216-464-4220
Mailing Address - Fax:
Practice Address - Street 1:5 SEVERANCE CIR STE 416
Practice Address - Street 2:
Practice Address - City:CLEVELAND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44118-1570
Practice Address - Country:US
Practice Address - Phone:216-291-0424
Practice Address - Fax:216-291-0425
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-03-5189-A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0198870Medicaid