Provider Demographics
NPI:1841340510
Name:TOOTLA, AMOD S (MD)
Entity type:Individual
Prefix:
First Name:AMOD
Middle Name:S
Last Name:TOOTLA
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 1:5220 HIGHLAND RD STE 200
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48327-1973
Mailing Address - Country:US
Mailing Address - Phone:248-334-3197
Mailing Address - Fax:248-335-8857
Practice Address - Street 1:5220 HIGHLAND RD STE 200
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327-1973
Practice Address - Country:US
Practice Address - Phone:248-334-3197
Practice Address - Fax:248-335-8857
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAT031237208600000X
MI4301031237208C00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2100453Medicaid
MI0639891Medicaid
MI0639891Medicare ID - Type Unspecified
MI0639891Medicaid