Provider Demographics
NPI:1568499838
Name:MITNICK, GARY R (DO)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:R
Last Name:MITNICK
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:4310 TRADEWINDS DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93035-1407
Mailing Address - Country:US
Mailing Address - Phone:805-985-5880
Mailing Address - Fax:805-984-9839
Practice Address - Street 1:4310 TRADEWINDS DR
Practice Address - Street 2:STE 300
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93035-1407
Practice Address - Country:US
Practice Address - Phone:805-985-5880
Practice Address - Fax:805-984-9839
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2009-12-29
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Provider Licenses
StateLicense IDTaxonomies
CA20A4379207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX43790Medicaid
CA00AX43790Medicaid
A93577Medicare UPIN