Provider Demographics
NPI:1740460351
Name:PITTMAN, MICHELLE ANTOINETTE (MD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANTOINETTE
Last Name:PITTMAN
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 1:777 JORDAN DR
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:AR
Mailing Address - Zip Code:71655-5719
Mailing Address - Country:US
Mailing Address - Phone:870-281-6549
Mailing Address - Fax:
Practice Address - Street 1:777 JORDAN DR
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:AR
Practice Address - Zip Code:71655-5719
Practice Address - Country:US
Practice Address - Phone:318-990-0060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-12
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-89902086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1041611Medicaid
LA1041611Medicaid