Provider Demographics
NPI:1295399913
Name:MITELMAN, MARAT (MD)
Entity Type:Individual
Prefix:DR
First Name:MARAT
Middle Name:
Last Name:MITELMAN
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 1:21 PATRICIA LN
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:12866-2811
Mailing Address - Country:US
Mailing Address - Phone:718-954-5205
Mailing Address - Fax:
Practice Address - Street 1:140 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-5009
Practice Address - Country:US
Practice Address - Phone:802-442-6361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-29
Last Update Date:2023-06-12
Deactivation Date:2023-05-22
Deactivation Code:
Reactivation Date:2023-06-12
Provider Licenses
StateLicense IDTaxonomies
390200000X
VT042.0017075207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program