Basic Information
| Provider Information | |||||||||
| NPI: | 1861421448 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MITTEREDER | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 CANAL LANDING BLVD. | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146265105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853684050 | ||||||||
| FaxNumber: | 5857236705 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 CANAL LANDING BLVD. | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146265105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853684050 | ||||||||
| FaxNumber: | 5857236705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 06/07/2016 | ||||||||
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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 | 207Q00000X | 191883 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01418831 | 05 | NY | MEDICAID |