Provider Demographics
NPI:1093790016
Name:MITTELL, DAVID CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:CHARLES
Last Name:MITTELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5000 WATERDAM PLAZA DR
Mailing Address - Street 2:SUITE 180
Mailing Address - City:MC MURRAY
Mailing Address - State:PA
Mailing Address - Zip Code:15317-5412
Mailing Address - Country:US
Mailing Address - Phone:724-942-4372
Mailing Address - Fax:724-942-4373
Practice Address - Street 1:5000 WATERDAM PLAZA DR
Practice Address - Street 2:SUITE 180
Practice Address - City:MC MURRAY
Practice Address - State:PA
Practice Address - Zip Code:15317-5412
Practice Address - Country:US
Practice Address - Phone:724-942-4372
Practice Address - Fax:724-942-4373
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD022476E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009586090002Medicaid
PAB39788Medicare UPIN
PA0009586090002Medicaid
PA147726Medicare PIN