Provider Demographics
NPI:1811006596
Name:MITNICK, JOSHUA P (DPM)
Entity Type:Individual
Prefix:DR
First Name:JOSHUA
Middle Name:P
Last Name:MITNICK
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 1:47 PENNY LN STE 1
Mailing Address - Street 2:
Mailing Address - City:WATSONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95076-6055
Mailing Address - Country:US
Mailing Address - Phone:831-728-8844
Mailing Address - Fax:831-763-7001
Practice Address - Street 1:47 PENNY LN STE 1
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-6055
Practice Address - Country:US
Practice Address - Phone:831-728-8844
Practice Address - Fax:831-763-7001
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE5006213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR006092Medicaid
ORV10525Medicare UPIN
OR006092Medicaid
ORP00416522Medicare PIN