Provider Demographics
NPI:1871829069
Name:ITTIARA, BRYANT T (DO)
Entity type:Individual
Prefix:
First Name:BRYANT
Middle Name:T
Last Name:ITTIARA
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 1:416 JAMES CIR
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-4545
Mailing Address - Country:US
Mailing Address - Phone:734-604-0017
Mailing Address - Fax:
Practice Address - Street 1:18707 ECORSE RD
Practice Address - Street 2:
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-2255
Practice Address - Country:US
Practice Address - Phone:734-682-3309
Practice Address - Fax:734-682-1488
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-23
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL1593593207L00000X
MI5101017919207LP2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine