Provider Demographics
NPI:1700193406
Name:MITRY, MICHAEL (DPM)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MITRY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 HIGHLAND AVE
Mailing Address - Street 2:STE 204
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02492-2617
Mailing Address - Country:US
Mailing Address - Phone:781-444-4044
Mailing Address - Fax:781-444-5044
Practice Address - Street 1:1410 HIGHLAND AVE STE 204
Practice Address - Street 2:
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02492-4460
Practice Address - Country:US
Practice Address - Phone:781-444-4044
Practice Address - Fax:781-444-5044
Is Sole Proprietor?:No
Enumeration Date:2010-09-02
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2384213ES0103X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110103207AMedicaid