Provider Demographics
NPI:1053305276
Name:MITTL, RAINER N (MD)
Entity Type:Individual
Prefix:DR
First Name:RAINER
Middle Name:N
Last Name:MITTL
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 1:1655 HAMMERSLEY AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-3113
Mailing Address - Country:US
Mailing Address - Phone:212-305-5030
Mailing Address - Fax:
Practice Address - Street 1:1655 HAMMERSLEY AVE FL 2
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-3113
Practice Address - Country:US
Practice Address - Phone:212-305-5030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-02
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY113621207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00206964Medicaid
NY00206964Medicaid