Provider Demographics
NPI:1265638464
Name:HARRY MITTELMAN, MD A PROF. CORP
Entity Type:Organization
Organization Name:HARRY MITTELMAN, MD A PROF. CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OM
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:TOCTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-331-6170
Mailing Address - Street 1:2017 W GARVEY AVE N
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-2050
Mailing Address - Country:US
Mailing Address - Phone:626-814-9604
Mailing Address - Fax:626-814-9704
Practice Address - Street 1:795 ALTOS OAKS DR
Practice Address - Street 2:
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94024-5428
Practice Address - Country:US
Practice Address - Phone:650-209-1100
Practice Address - Fax:650-209-1110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC30674207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA34323Medicare UPIN
CA05-C001240Medicare ID - Type UnspecifiedMEDICARE ID