Provider Demographics
NPI:1649326661
Name:PROFFMAN, MITCHELL GARY (DC)
Entity type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:GARY
Last Name:PROFFMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14402 69TH AVE
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-1710
Mailing Address - Country:US
Mailing Address - Phone:718-268-9080
Mailing Address - Fax:718-544-2381
Practice Address - Street 1:14402 69TH AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11367-1710
Practice Address - Country:US
Practice Address - Phone:718-268-9080
Practice Address - Fax:718-544-2381
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX2684111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY54133Medicare ID - Type UnspecifiedPROVIDER NUMBER