Provider Demographics
NPI:1790736312
Name:MITTELBRONN, MICHELE A (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:A
Last Name:MITTELBRONN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:999 LAKE HUNTER CIR
Mailing Address - Street 2:SUITE B
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-5427
Mailing Address - Country:US
Mailing Address - Phone:843-881-2265
Mailing Address - Fax:843-881-2789
Practice Address - Street 1:999 LAKE HUNTER CIR
Practice Address - Street 2:SUITE B
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-5427
Practice Address - Country:US
Practice Address - Phone:843-881-2265
Practice Address - Fax:843-881-2789
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22838207N00000X, 207ND0900X, 207NP0225X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC200070804OtherTAX ID
SC200070804OtherTAX ID
SC7692Medicare ID - Type Unspecified