Provider Demographics
NPI:1679751358
Name:MITTELSTAEDT, BRENT RONALD (DO)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:RONALD
Last Name:MITTELSTAEDT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3021 SAINT JOHNS DR
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37129-5834
Mailing Address - Country:US
Mailing Address - Phone:732-801-6962
Mailing Address - Fax:
Practice Address - Street 1:3400 LEBANON RD
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129-1392
Practice Address - Country:US
Practice Address - Phone:615-867-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-05
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS014462207W00000X
FLOS13484207W00000X
MA278557207W00000X
TN4519207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology