Provider Demographics
NPI:1255338026
Name:MITTELMAN, MARK (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MITTELMAN
Suffix:
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 1:5220 GREENS DAIRY RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-4612
Mailing Address - Country:US
Mailing Address - Phone:919-256-3576
Mailing Address - Fax:
Practice Address - Street 1:262 LEROY GEORGE DR
Practice Address - Street 2:STE X
Practice Address - City:CLYDE
Practice Address - State:NC
Practice Address - Zip Code:28721-7430
Practice Address - Country:US
Practice Address - Phone:828-452-8346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2003006682085R0202X, 2085R0204X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89134MRMedicaid
NCBM4573627OtherDEA
NC89134MRMedicaid
NCBM4573627OtherDEA