Provider Demographics
NPI:1821071705
Name:MITTELDORF, STEPHEN EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:EDWARD
Last Name:MITTELDORF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 UNIVERSITY PKWY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34243-2973
Mailing Address - Country:US
Mailing Address - Phone:941-351-9995
Mailing Address - Fax:941-351-6286
Practice Address - Street 1:2401 UNIVERSITY PKWY
Practice Address - Street 2:SUITE 202
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34243-2973
Practice Address - Country:US
Practice Address - Phone:941-351-9995
Practice Address - Fax:941-351-6286
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78671207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL49340Medicare ID - Type Unspecified
B37144Medicare UPIN