Provider Demographics
NPI:1003226051
Name:MITKOV, MARIO (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:MITKOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 PROFESSIONAL PARK DR STE 150
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1307
Mailing Address - Country:US
Mailing Address - Phone:336-724-2434
Mailing Address - Fax:336-607-8061
Practice Address - Street 1:3107 BRASSFIELD RD STE 300
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-2074
Practice Address - Country:US
Practice Address - Phone:336-545-8133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-30
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101266560207N00000X, 207ND0101X
FLME124757207N00000X
NC2019-00501207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery