Provider Demographics
NPI:1821458811
Name:AL ITHAWI, KUTAIBA
Entity Type:Individual
Prefix:
First Name:KUTAIBA
Middle Name:
Last Name:AL ITHAWI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5205 S 13TH ST UNIT E
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53221-3648
Mailing Address - Country:US
Mailing Address - Phone:414-477-3398
Mailing Address - Fax:
Practice Address - Street 1:5205 S 13TH ST UNIT E
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53221-3648
Practice Address - Country:US
Practice Address - Phone:414-477-3398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service