Provider Demographics
NPI:1407480023
Name:MITMAN, GREG
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:
Last Name:MITMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 EAST ATLANTIC AVENUE
Mailing Address - Street 2:
Mailing Address - City:AUDUBON
Mailing Address - State:NJ
Mailing Address - Zip Code:08106-1469
Mailing Address - Country:US
Mailing Address - Phone:856-796-3432
Mailing Address - Fax:
Practice Address - Street 1:7 EAST ATLANTIC AVENUE
Practice Address - Street 2:
Practice Address - City:AUDUBON
Practice Address - State:NJ
Practice Address - Zip Code:08106-1469
Practice Address - Country:US
Practice Address - Phone:856-796-3432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-24
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer