Provider Demographics
NPI:1346335668
Name:MISTRETTA, JOHN MARK (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MARK
Last Name:MISTRETTA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 MCMASTER ST STE 1
Mailing Address - Street 2:
Mailing Address - City:OWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13827-1029
Mailing Address - Country:US
Mailing Address - Phone:607-687-2242
Mailing Address - Fax:607-687-9128
Practice Address - Street 1:6 MCMASTER ST STE 1
Practice Address - Street 2:
Practice Address - City:OWEGO
Practice Address - State:NY
Practice Address - Zip Code:13827-1029
Practice Address - Country:US
Practice Address - Phone:607-687-2242
Practice Address - Fax:607-687-9128
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX005973-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000129776OtherEXCELLUS BC/BS
NY000129776OtherEXCELLUS BC/BS
NY51907CMedicare ID - Type Unspecified