Provider Demographics
NPI:1710087408
Name:MIETZELFELD, LAWRENCE OTTO JR (DC)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:OTTO
Last Name:MIETZELFELD
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ONEONTA
Mailing Address - State:NY
Mailing Address - Zip Code:13820-2516
Mailing Address - Country:US
Mailing Address - Phone:607-432-4330
Mailing Address - Fax:
Practice Address - Street 1:55 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ONEONTA
Practice Address - State:NY
Practice Address - Zip Code:13820-2516
Practice Address - Country:US
Practice Address - Phone:607-432-4330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX003096111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC03096-7OtherWORKERS' COMPENSATION
NY38820CMedicare ID - Type Unspecified