Provider Demographics
NPI:1255494811
Name:KORN, MITCHELL JOSEPH (PT)
Entity Type:Individual
Prefix:MR
First Name:MITCHELL
Middle Name:JOSEPH
Last Name:KORN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:845 STATE ROUTE 17M
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NY
Mailing Address - Zip Code:10950-1606
Mailing Address - Country:US
Mailing Address - Phone:845-782-7780
Mailing Address - Fax:845-782-7290
Practice Address - Street 1:845 STATE ROUTE 17M
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NY
Practice Address - Zip Code:10950-1606
Practice Address - Country:US
Practice Address - Phone:845-782-7780
Practice Address - Fax:845-782-7290
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6408225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ527510Medicare ID - Type Unspecified