Provider Demographics
NPI:1740274604
Name:MITKOFF, NATHAN BERNARD (MD)
Entity type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:BERNARD
Last Name:MITKOFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:178 WASHINGTON AVENUE EXT
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-5304
Mailing Address - Country:US
Mailing Address - Phone:518-262-5735
Mailing Address - Fax:518-262-5743
Practice Address - Street 1:178 WASHINGTON AVENUE EXT
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-5304
Practice Address - Country:US
Practice Address - Phone:518-262-5735
Practice Address - Fax:518-262-5743
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY176508-1207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01558552Medicaid
NYF10408Medicare UPIN
NY01558552Medicaid