Basic Information
| Provider Information | |||||||||
| NPI: | 1467568667 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DAVID C. MITTELL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | WATERDAM FAMILY PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5000 WATERDAM PLAZA DR | ||||||||
| Address2: | SUITE 180 | ||||||||
| City: | MCMURRAY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 153175412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7249424372 | ||||||||
| FaxNumber: | 7249424373 | ||||||||
| Practice Location | |||||||||
| Address1: | 5000 WATERDAM PLAZA DR | ||||||||
| Address2: | SUITE 180 | ||||||||
| City: | MCMURRAY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 153175412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7249424372 | ||||||||
| FaxNumber: | 7249424373 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 06/23/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MITTELL | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | CHARLES | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 7249424372 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD-022476-E | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0009586090002 | 05 | PA | MEDICAID |