Provider Demographics
NPI:1295725513
Name:MITTELSTADT, PAUL EVERETT (MD)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:EVERETT
Last Name:MITTELSTADT
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:PO BOX 28247
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85285-8247
Mailing Address - Country:US
Mailing Address - Phone:480-967-6500
Mailing Address - Fax:480-967-6540
Practice Address - Street 1:111 E WISCONSIN AVE STE 2100
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-4809
Practice Address - Country:US
Practice Address - Phone:414-290-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA89106207P00000X
WI25846207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB221597Medicare PIN