Provider Demographics
NPI:1669510913
Name:EHRLICH, MITCHELL W (MD)
Entity type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:W
Last Name:EHRLICH
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 1:939 GERRY AVE
Mailing Address - Street 2:
Mailing Address - City:LIDO BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-5216
Mailing Address - Country:US
Mailing Address - Phone:631-736-4321
Mailing Address - Fax:
Practice Address - Street 1:1055 PORTION RD
Practice Address - Street 2:SUITE 124
Practice Address - City:FARMINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:11738-2299
Practice Address - Country:US
Practice Address - Phone:631-736-4321
Practice Address - Fax:631-736-4370
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY155061208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01023707Medicaid
NY01023707Medicaid
A63877Medicare UPIN