Provider Demographics
NPI:1972289379
Name:KETTANA, HUTHAIFA MUTHANNA (MD)
Entity Type:Individual
Prefix:
First Name:HUTHAIFA
Middle Name:MUTHANNA
Last Name:KETTANA
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 1:4 GRAND HALL
Mailing Address - Street 2:HARROW DRIVE
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904
Mailing Address - Country:US
Mailing Address - Phone:442-322-7805
Mailing Address - Fax:
Practice Address - Street 1:640 S. STATE ST
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901
Practice Address - Country:US
Practice Address - Phone:302-674-4700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-22
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC7-0018348207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty