Provider Demographics
NPI:1790852531
Name:MITKOWSKI, GARY (RPAC)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:
Last Name:MITKOWSKI
Suffix:
Gender:M
Credentials:RPAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 TITUS PLACE
Mailing Address - Street 2:
Mailing Address - City:WALTON
Mailing Address - State:NY
Mailing Address - Zip Code:13856
Mailing Address - Country:US
Mailing Address - Phone:607-865-2188
Mailing Address - Fax:607-865-2238
Practice Address - Street 1:1 TITUS PLACE
Practice Address - Street 2:
Practice Address - City:WALTON
Practice Address - State:NY
Practice Address - Zip Code:13856
Practice Address - Country:US
Practice Address - Phone:607-865-2188
Practice Address - Fax:607-865-2238
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007054207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine