Provider Demographics
NPI:1649390964
Name:MITSAK, RICHARD ANDREW (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:ANDREW
Last Name:MITSAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:13311 EAST BUCK RUN RD
Mailing Address - City:ROCKBRIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:43149-0130
Mailing Address - Country:US
Mailing Address - Phone:740-385-6342
Mailing Address - Fax:
Practice Address - Street 1:1640 NEIL AVE
Practice Address - Street 2:ROOM 438
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43201
Practice Address - Country:US
Practice Address - Phone:614-292-5766
Practice Address - Fax:614-688-3440
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OHOHIO35337042084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0321539Medicaid
OH0321539Medicaid
OHMI0374792Medicare ID - Type Unspecified