Provider Demographics
NPI:1750315651
Name:ITTNER, ERIC J (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:J
Last Name:ITTNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 220
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-0220
Mailing Address - Country:US
Mailing Address - Phone:906-225-3630
Mailing Address - Fax:906-225-4537
Practice Address - Street 1:1414 W FAIR AVE
Practice Address - Street 2:SUITE 36
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2675
Practice Address - Country:US
Practice Address - Phone:906-225-3864
Practice Address - Fax:906-225-3851
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301042825207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1585743Medicaid
MI1585743Medicaid