Provider Demographics
NPI:1356306724
Name:MITRIUS, JOAN C (MD)
Entity Type:Individual
Prefix:DR
First Name:JOAN
Middle Name:C
Last Name:MITRIUS
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:77 W FOREST AVE
Mailing Address - Street 2:STE 210
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-1479
Mailing Address - Country:US
Mailing Address - Phone:928-773-2547
Mailing Address - Fax:928-773-2548
Practice Address - Street 1:77 W FOREST AVE
Practice Address - Street 2:STE 210
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1479
Practice Address - Country:US
Practice Address - Phone:928-773-2547
Practice Address - Fax:928-773-2548
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ23253207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ312728Medicaid
AZG07332Medicare UPIN
AZ312728Medicaid