Provider Demographics
NPI:1821071382
Name:MYTINGER, JESSE AIDEN (DPM)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:AIDEN
Last Name:MYTINGER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1601 UNION AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:NATRONA HEIGHTS
Mailing Address - State:PA
Mailing Address - Zip Code:15065-2133
Mailing Address - Country:US
Mailing Address - Phone:724-226-0544
Mailing Address - Fax:724-226-2172
Practice Address - Street 1:127 COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:VANDERGRIFT
Practice Address - State:PA
Practice Address - Zip Code:15690-1101
Practice Address - Country:US
Practice Address - Phone:724-567-7520
Practice Address - Fax:724-568-2169
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC005745213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1013170390001Medicaid
V04964Medicare UPIN
PA1013170390001Medicaid