Provider Demographics
NPI:1861486714
Name:TAMIRISA, MITHILESH (MD)
Entity type:Individual
Prefix:
First Name:MITHILESH
Middle Name:
Last Name:TAMIRISA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MITZI
Other - Middle Name:
Other - Last Name:TAMIRISA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:516 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:ROSSFORD
Mailing Address - State:OH
Mailing Address - Zip Code:43460-1055
Mailing Address - Country:US
Mailing Address - Phone:419-410-4898
Mailing Address - Fax:419-318-4395
Practice Address - Street 1:516 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:ROSSFORD
Practice Address - State:OH
Practice Address - Zip Code:43460-1055
Practice Address - Country:US
Practice Address - Phone:419-410-4898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35050201207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0628888Medicaid
OH0628888Medicaid