Provider Demographics
NPI:1093298762
Name:MATTHEW MITTELBRONN, MD MPH
Entity Type:Organization
Organization Name:MATTHEW MITTELBRONN, MD MPH
Other - Org Name:LAKEVIEW DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:MITTELBRONN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:504-813-3318
Mailing Address - Street 1:5608 MALVEY AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-5107
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3918 TELEPHONE RD STE 100
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-2933
Practice Address - Country:US
Practice Address - Phone:817-752-5256
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-10
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty