Provider Demographics
NPI:1922072701
Name:NEEDLEMAN, MITCHELL (DPM)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:
Last Name:NEEDLEMAN
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 1:16A PARK PLACE
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226
Mailing Address - Country:US
Mailing Address - Phone:618-234-8333
Mailing Address - Fax:618-234-8349
Practice Address - Street 1:16A PARK PLACE
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226
Practice Address - Country:US
Practice Address - Phone:618-234-8333
Practice Address - Fax:618-234-8349
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-16
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003942213E00000X
MO000545213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO306939307Medicaid
MO000021187Medicare ID - Type Unspecified
IL776370Medicare ID - Type Unspecified
MO306939307Medicaid