Provider Demographics
NPI:1073630646
Name:GERTZ, MITCHELL MARK (DPM)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:MARK
Last Name:GERTZ
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:MA
Mailing Address - Zip Code:02149-3126
Mailing Address - Country:US
Mailing Address - Phone:617-387-6118
Mailing Address - Fax:
Practice Address - Street 1:906 BROADWAY
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:MA
Practice Address - Zip Code:02149-3126
Practice Address - Country:US
Practice Address - Phone:617-387-6118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1699213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0350613Medicaid
MA0350613Medicaid
MAT58749Medicare UPIN