Provider Demographics
NPI:1023060696
Name:MITTICA, NICHOLAS M JR (MD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:M
Last Name:MITTICA
Suffix:JR
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 1:604 W SPRING ST
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88061-4847
Mailing Address - Country:US
Mailing Address - Phone:575-388-4464
Mailing Address - Fax:575-388-2014
Practice Address - Street 1:604 W SPRING ST
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-4847
Practice Address - Country:US
Practice Address - Phone:575-388-4464
Practice Address - Fax:575-388-2014
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2004-0317207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM27502562Medicaid
NM27502562Medicaid