Provider Demographics
NPI:1346392842
Name:MITTLEMAN, EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:MITTLEMAN
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 1:2015 EL VISTA COURT
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208
Mailing Address - Country:US
Mailing Address - Phone:714-740-1778
Mailing Address - Fax:714-740-1913
Practice Address - Street 1:21707 HAWTHORNE BLVD
Practice Address - Street 2:STE 101 PERFORMANCE HEALTH MEDICAL GROUP
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503
Practice Address - Country:US
Practice Address - Phone:310-792-2430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA28401207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA28401AMedicare ID - Type Unspecified
A83742Medicare UPIN