Provider Demographics
NPI:1568407526
Name:MITNICK, ALAN H (MD)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:H
Last Name:MITNICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3408 ENGLEMEADE RD
Mailing Address - Street 2:
Mailing Address - City:PIKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-1601
Mailing Address - Country:US
Mailing Address - Phone:410-484-1416
Mailing Address - Fax:
Practice Address - Street 1:5400 OLD COURT RD
Practice Address - Street 2:SUITE 105
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-5100
Practice Address - Country:US
Practice Address - Phone:410-922-1133
Practice Address - Fax:410-922-9740
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0007985208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD026021500Medicaid
MD026021500Medicaid
S230BRMedicare ID - Type Unspecified