Provider Demographics
NPI:1942415732
Name:ITTICHERIA, ACHAMMA S (MD)
Entity Type:Individual
Prefix:
First Name:ACHAMMA
Middle Name:S
Last Name:ITTICHERIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3299
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89702-3299
Mailing Address - Country:US
Mailing Address - Phone:775-222-0044
Mailing Address - Fax:888-700-0187
Practice Address - Street 1:828 LANE ALLEN RD STE 219
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504
Practice Address - Country:US
Practice Address - Phone:502-498-4071
Practice Address - Fax:888-423-5216
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY44836207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100263350Medicaid
KY7100263350Medicaid