Provider Demographics
NPI: | 1851305221 |
---|---|
Name: | TRITTSCHUH, JOHN R (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | JOHN |
Middle Name: | R |
Last Name: | TRITTSCHUH |
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: | 4016 W MAIN ST |
Mailing Address - Street 2: | |
Mailing Address - City: | KALAMAZOO |
Mailing Address - State: | MI |
Mailing Address - Zip Code: | 49006 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 269-344-3366 |
Mailing Address - Fax: | 269-344-3676 |
Practice Address - Street 1: | 4016 W MAIN ST |
Practice Address - Street 2: | |
Practice Address - City: | KALAMAZOO |
Practice Address - State: | MI |
Practice Address - Zip Code: | 49006 |
Practice Address - Country: | US |
Practice Address - Phone: | 269-344-3366 |
Practice Address - Fax: | 269-344-3676 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-07-28 |
Last Update Date: | 2007-07-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MI | JT031851 | 207W00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207W00000X | Allopathic & Osteopathic Physicians | Ophthalmology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MI | 180399449 | Other | BLUE CROSS BLUE SHIELD |
MI | 0524240001 | Other | ADMINISTAR FEDERAL |
MI | 180012001 | Other | PALAMETTO GBA |
MI | 0830973 | Other | IBA PHP |
MI | 102966940 | Medicaid | |
MI | 0830973 | Other | IBA PHP |
MI | 102966940 | Medicaid |