Provider Demographics
NPI:1255322996
Name:MITTAUER, MARK WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
Last Name:MITTAUER
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:RTE 12 BLDG 449
Mailing Address - Street 2:ATTN: PROFESSIONAL AFFAIRS
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06349-5600
Mailing Address - Country:US
Mailing Address - Phone:860-694-2377
Mailing Address - Fax:860-694-2590
Practice Address - Street 1:RTE 12 BLDG 449
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06349-5600
Practice Address - Country:US
Practice Address - Phone:860-694-2377
Practice Address - Fax:860-694-2590
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME485852084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN