Provider Demographics
NPI:1720130248
Name:MITNICK, DAVID A (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:MITNICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3 KEITH PL
Mailing Address - Street 2:
Mailing Address - City:GLEN ROCK
Mailing Address - State:NJ
Mailing Address - Zip Code:07452-3712
Mailing Address - Country:US
Mailing Address - Phone:201-880-7575
Mailing Address - Fax:201-880-7570
Practice Address - Street 1:3 KEITH PL
Practice Address - Street 2:
Practice Address - City:GLEN ROCK
Practice Address - State:NJ
Practice Address - Zip Code:07452-3712
Practice Address - Country:US
Practice Address - Phone:201-880-7575
Practice Address - Fax:201-880-7570
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2022-11-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NJMA578772084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ727006Medicare UPIN