Basic Information
| Provider Information | |||||||||
| NPI: | 1578593851 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MUTNICK | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3959 BROADWAY | ||||||||
| Address2: | COLUMBIA UNVERSITY DEPARTMENT PEDIATRIC | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100321559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123047250 | ||||||||
| FaxNumber: | 2125441974 | ||||||||
| Practice Location | |||||||||
| Address1: | 3959 BROADWAY | ||||||||
| Address2: | COLUMBIA UNVERSITY DEPARTMENT PEDIATRIC | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100321559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123047250 | ||||||||
| FaxNumber: | 2125441974 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 08/14/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 227307 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 02726850 | 05 | NY | MEDICAID |