Provider Demographics
NPI:1275504367
Name:MITNICK, BLAKE (OD)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:
Last Name:MITNICK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FLOYD
Mailing Address - State:VA
Mailing Address - Zip Code:24091-3190
Mailing Address - Country:US
Mailing Address - Phone:540-745-8733
Mailing Address - Fax:540-745-6644
Practice Address - Street 1:211 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FLOYD
Practice Address - State:VA
Practice Address - Zip Code:24091-3190
Practice Address - Country:US
Practice Address - Phone:540-745-8733
Practice Address - Fax:540-745-6644
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000582152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAU40367Medicare UPIN