Provider Demographics
NPI:1962483511
Name:MITSOS, ANGELO J (DPM)
Entity Type:Individual
Prefix:
First Name:ANGELO
Middle Name:J
Last Name:MITSOS
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 1:3124 WILMINGTON RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:NEW CASTLE
Mailing Address - State:PA
Mailing Address - Zip Code:16105-1100
Mailing Address - Country:US
Mailing Address - Phone:724-656-1680
Mailing Address - Fax:724-656-1683
Practice Address - Street 1:3124 WILMINGTON RD
Practice Address - Street 2:SUITE 106
Practice Address - City:NEW CASTLE
Practice Address - State:PA
Practice Address - Zip Code:16105-1100
Practice Address - Country:US
Practice Address - Phone:724-656-1680
Practice Address - Fax:724-656-1683
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC002342L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0008523790004Medicaid
OH0488422OtherMEDICAID PIN
OHPO0329085OtherRAILROAD MEDICARE PIN
PA233542Medicare PIN
OH0488422OtherMEDICAID PIN
PAT27682Medicare UPIN
OHMI0501516Medicare PIN