Provider Demographics
NPI:1528595352
Name:MITTENDORF, ISAAC (MD)
Entity Type:Individual
Prefix:
First Name:ISAAC
Middle Name:
Last Name:MITTENDORF
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 1:2331 NEW HOLT RD
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-7404
Mailing Address - Country:US
Mailing Address - Phone:270-441-4777
Mailing Address - Fax:270-441-4777
Practice Address - Street 1:2331 NEW HOLT RD
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-7404
Practice Address - Country:US
Practice Address - Phone:270-441-4777
Practice Address - Fax:270-441-4780
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC41002207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine