Provider Demographics
NPI:1407929375
Name:MITTMAN, AVERY C (MD)
Entity Type:Individual
Prefix:
First Name:AVERY
Middle Name:C
Last Name:MITTMAN
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:PO BOX 2757
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92859-0757
Mailing Address - Country:US
Mailing Address - Phone:714-973-2650
Mailing Address - Fax:714-973-2655
Practice Address - Street 1:1154 N EUCLID ST
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-1955
Practice Address - Country:US
Practice Address - Phone:714-635-6272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG65682207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF52802Medicare UPIN
CAG65682DMedicare ID - Type Unspecified