Provider Demographics
NPI:1669414363
Name:LETIZIA, KATHLEEN A (MD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:LETIZIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 PAGE RD
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374-8798
Mailing Address - Country:US
Mailing Address - Phone:910-295-5511
Mailing Address - Fax:
Practice Address - Street 1:15 REGIONAL DR
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-8850
Practice Address - Country:US
Practice Address - Phone:910-295-5511
Practice Address - Fax:910-235-3452
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9900916207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8912295Medicaid
SCN0091COtherSC MEDICAID PROVIDER#
NC0403888OtherEVERCARE
NC110189349OtherPALMETTO GBA PROVIDER#
NCFH1001315OtherFIRSTCAROLINACARE PROV.#
NC12295OtherBC/BS NC PROVIDER#
NC90671OtherMEDCOST PROVIDER#
NC8912295Medicaid
NC110189349OtherPALMETTO GBA PROVIDER#