Basic Information
| Provider Information | |||||||||
| NPI: | 1114914900 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIATRAK | ||||||||
| FirstName: | MITCHELL | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 310 N L ROGERS WELLS BLVD | ||||||||
| Address2: | |||||||||
| City: | GLASGOW | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421411300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706595965 | ||||||||
| FaxNumber: | 2706595856 | ||||||||
| Practice Location | |||||||||
| Address1: | 310 N L ROGERS WELLS BLVD | ||||||||
| Address2: | |||||||||
| City: | GLASGOW | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421411300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706595965 | ||||||||
| FaxNumber: | 2706595856 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2005 | ||||||||
| LastUpdateDate: | 09/08/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 41813 | TN | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | 42456 | KY | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 3833243 | 05 | TN | MEDICAID |