Provider Demographics
NPI:1437330867
Name:MITTMANN, ROY H (OD)
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:H
Last Name:MITTMANN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 HUGUENOT RD
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-2428
Mailing Address - Country:US
Mailing Address - Phone:804-794-3937
Mailing Address - Fax:804-794-9216
Practice Address - Street 1:1601 HUGUENOT RD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-2428
Practice Address - Country:US
Practice Address - Phone:804-794-3937
Practice Address - Fax:804-794-9216
Is Sole Proprietor?:No
Enumeration Date:2007-11-14
Last Update Date:2014-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000405152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAOP2564OtherEYEMED PROVIDER ID
VA356769OtherANTHEM