Provider Demographics
NPI:1750481255
Name:ITANI, ABDUL LATIF (MD)
Entity Type:Individual
Prefix:DR
First Name:ABDUL
Middle Name:LATIF
Last Name:ITANI
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 1:2785 SOM CENTER RD
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-9139
Mailing Address - Country:US
Mailing Address - Phone:440-975-5575
Mailing Address - Fax:440-944-0920
Practice Address - Street 1:2785 SOM CENTER RD
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-9139
Practice Address - Country:US
Practice Address - Phone:440-975-5575
Practice Address - Fax:440-944-0920
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350433691207T00000X
PA035432L207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0408919Medicaid
OHIT0462879Medicare ID - Type Unspecified
OH0408919Medicaid