Provider Demographics
NPI:1669730834
Name:KAUFMAN, MITCHELL GLENN
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:GLENN
Last Name:KAUFMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1824 MADISON PL
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-2630
Mailing Address - Country:US
Mailing Address - Phone:347-351-2334
Mailing Address - Fax:
Practice Address - Street 1:3419 AVENUE S
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-4825
Practice Address - Country:US
Practice Address - Phone:347-351-2334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-25
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6896-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician