Provider Demographics
NPI:1407894579
Name:MUTCHNICK, MILTON G (MD)
Entity Type:Individual
Prefix:
First Name:MILTON
Middle Name:G
Last Name:MUTCHNICK
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 1:400 MACK AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2136
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4160 JOHN R ST
Practice Address - Street 2:HARPER PROFESSIONAL BLDG SUITE 917
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2017
Practice Address - Country:US
Practice Address - Phone:313-745-4525
Practice Address - Fax:313-745-0011
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301028211207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P30630113Medicare PIN