Provider Demographics
NPI:1508876194
Name:MITTELBERGER, JAMES (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:MITTELBERGER
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 1:6155 GIRVIN DR
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-2444
Mailing Address - Country:US
Mailing Address - Phone:510-387-0585
Mailing Address - Fax:510-291-2970
Practice Address - Street 1:6155 GIRVIN DR
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-2444
Practice Address - Country:US
Practice Address - Phone:510-387-0585
Practice Address - Fax:510-291-2970
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG58513207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G585130Medicaid
CA00G585130Medicare ID - Type Unspecified
A90018Medicare UPIN