Provider Demographics
NPI:1477787612
Name:DITURSI, MARIUS KILLIAN NIKOLAS (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:MARIUS KILLIAN
Middle Name:NIKOLAS
Last Name:DITURSI
Suffix:
Gender:
Credentials:MD, PHD
Other - Prefix:
Other - First Name:MARY KATHLEEN
Other - Middle Name:RILEY
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1495 15TH ST
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-4302
Mailing Address - Country:US
Mailing Address - Phone:518-210-5962
Mailing Address - Fax:
Practice Address - Street 1:1495 15TH ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-4302
Practice Address - Country:US
Practice Address - Phone:518-810-4680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-01
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY263723208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03519624Medicaid