Provider Demographics
NPI:1356342992
Name:MITNICK, MARC (DPM)
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:
Last Name:MITNICK
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 1:1 STUART CT
Mailing Address - Street 2:
Mailing Address - City:PINE BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:07058-9646
Mailing Address - Country:US
Mailing Address - Phone:973-882-9736
Mailing Address - Fax:
Practice Address - Street 1:360 SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:NJ
Practice Address - Zip Code:07901-4608
Practice Address - Country:US
Practice Address - Phone:908-522-0761
Practice Address - Fax:908-926-2111
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-04
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00109000213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ222236123OtherTAX ID
NJ222236123OtherTAX ID
NJ045631Medicare ID - Type Unspecified