Provider Demographics
NPI:1912575887
Name:NITTALA, SIMEON (DO)
Entity Type:Individual
Prefix:
First Name:SIMEON
Middle Name:
Last Name:NITTALA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 ALBION AVE
Mailing Address - Street 2:
Mailing Address - City:ROSELLE
Mailing Address - State:IL
Mailing Address - Zip Code:60172-1075
Mailing Address - Country:US
Mailing Address - Phone:630-456-6254
Mailing Address - Fax:
Practice Address - Street 1:1464 JEFFERSON ST N
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:WV
Practice Address - Zip Code:24901-1380
Practice Address - Country:US
Practice Address - Phone:304-645-3220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty