Provider Demographics
NPI:1831312016
Name:PERITZ, MITCHELL MARK (DC)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:MARK
Last Name:PERITZ
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1017 LARAMIE BLVD UNIT D
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-4725
Mailing Address - Country:US
Mailing Address - Phone:303-253-4204
Mailing Address - Fax:
Practice Address - Street 1:3920 N UNION BLVD STE 160
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-4907
Practice Address - Country:US
Practice Address - Phone:719-632-4754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NYX003634-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program