Provider Demographics
NPI:1174182224
Name:MITTLIEDER, JAY (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:
Last Name:MITTLIEDER
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3821 COUNTY ROAD 19 S
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-2249
Mailing Address - Country:US
Mailing Address - Phone:701-509-0589
Mailing Address - Fax:
Practice Address - Street 1:3821 COUNTY ROAD 19 S
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-2249
Practice Address - Country:US
Practice Address - Phone:701-509-0589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist