Provider Demographics
NPI:1205852290
Name:MITTLE, SUMIT (MD)
Entity Type:Individual
Prefix:
First Name:SUMIT
Middle Name:
Last Name:MITTLE
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 1:2001 MARCUS AVE
Mailing Address - Street 2:SUITE N-122
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1011
Mailing Address - Country:US
Mailing Address - Phone:516-437-5600
Mailing Address - Fax:516-437-7428
Practice Address - Street 1:2001 MARCUS AVE
Practice Address - Street 2:SUITE N-122
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1011
Practice Address - Country:US
Practice Address - Phone:516-437-5600
Practice Address - Fax:516-437-7428
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY232207207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02656137Medicaid
NY06795Medicare ID - Type UnspecifiedGHI MEDICARE NUMBER
NYI22291Medicare UPIN
NY600P21Medicare ID - Type UnspecifiedEMPIRE MEDICARE NUMBER