Provider Demographics
NPI:1073792131
Name:MITCHELL S. GITTELMAN, D.O., P.A.
Entity Type:Organization
Organization Name:MITCHELL S. GITTELMAN, D.O., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:SENDER
Authorized Official - Last Name:GITTELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:410-860-0100
Mailing Address - Street 1:31413 WINTERPLACE PKWY
Mailing Address - Street 2:103
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-1877
Mailing Address - Country:US
Mailing Address - Phone:410-860-0100
Mailing Address - Fax:410-860-4894
Practice Address - Street 1:31413 WINTERPLACE PKWY
Practice Address - Street 2:103
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-1877
Practice Address - Country:US
Practice Address - Phone:410-860-0100
Practice Address - Fax:410-860-4894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-25
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH54827207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD368280300Medicaid
MDH04398Medicare UPIN
MD339MMedicare PIN