Provider Demographics
NPI:1083681993
Name:MUTIC, MARIO (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:
Last Name:MUTIC
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:PO BOX 1722
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10602-1722
Mailing Address - Country:US
Mailing Address - Phone:914-683-0443
Mailing Address - Fax:914-683-8620
Practice Address - Street 1:170 MAPLE AVE
Practice Address - Street 2:SUITE G1
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10601-4710
Practice Address - Country:US
Practice Address - Phone:914-683-0443
Practice Address - Fax:914-683-8620
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY257090207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALP00312169OtherRAILROAD MEDICARE NUMBER
AL009934086Medicaid
AL51531097OtherBCBS PROVIDER
NY257090OtherMEDICAL LICENSE
ALDB8444OtherRAILROAD MEDICARE GRP
ALDB8444OtherRAILROAD MEDICARE GRP
AL051556442Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER