Provider Demographics
NPI:1821198029
Name:SATTASIRI, WITTAYA MICHAEL (MD)
Entity Type:Individual
Prefix:MR
First Name:WITTAYA
Middle Name:MICHAEL
Last Name:SATTASIRI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:WITIYA
Other - Middle Name:MICHAEL
Other - Last Name:SATASIRI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 305172 DEPT 163
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37230-5172
Mailing Address - Country:US
Mailing Address - Phone:407-788-1906
Mailing Address - Fax:407-865-6406
Practice Address - Street 1:808 S JAMES M CAMPBELL BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-4338
Practice Address - Country:US
Practice Address - Phone:407-788-1906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000037469174400000X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4113874Medicaid
TN4113874OtherBLUE CROSS BLUE SHIELD
TN4113874Medicaid
3893277Medicare PIN
I0828Medicare UPIN