Provider Demographics
NPI:1467568667
Name:DAVID C. MITTELL
Entity Type:Organization
Organization Name:DAVID C. MITTELL
Other - Org Name:WATERDAM FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:MITTELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-942-4372
Mailing Address - Street 1:5000 WATERDAM PLAZA DR
Mailing Address - Street 2:SUITE 180
Mailing Address - City:MCMURRAY
Mailing Address - State:PA
Mailing Address - Zip Code:15317-5412
Mailing Address - Country:US
Mailing Address - Phone:724-942-4372
Mailing Address - Fax:724-942-4373
Practice Address - Street 1:5000 WATERDAM PLAZA DR
Practice Address - Street 2:SUITE 180
Practice Address - City:MCMURRAY
Practice Address - State:PA
Practice Address - Zip Code:15317-5412
Practice Address - Country:US
Practice Address - Phone:724-942-4372
Practice Address - Fax:724-942-4373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-022476-E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009586090002Medicaid
PAB39788Medicare UPIN
PA0009586090002Medicaid