Provider Demographics
NPI:1942278767
Name:MITTELSTAEDT, BRIAN W (DC)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:W
Last Name:MITTELSTAEDT
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 1:601 S RACE ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-6400
Mailing Address - Country:US
Mailing Address - Phone:360-452-7636
Mailing Address - Fax:360-457-4221
Practice Address - Street 1:601 S RACE ST
Practice Address - Street 2:SUITE C
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-6400
Practice Address - Country:US
Practice Address - Phone:360-452-7636
Practice Address - Fax:360-457-4221
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1365111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8808875Medicare ID - Type Unspecified
WAT10535Medicare UPIN