Provider Demographics
NPI:1841274560
Name:MITTLEMAN, CRAIG BRUCE (MD)
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:BRUCE
Last Name:MITTLEMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:20 YORK STREET, CB-329
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3220
Mailing Address - Country:US
Mailing Address - Phone:203-688-1734
Mailing Address - Fax:203-688-9638
Practice Address - Street 1:365 MONTAUK AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320
Practice Address - Country:US
Practice Address - Phone:860-442-0711
Practice Address - Fax:203-688-9638
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT033738207P00000X
RICMD16915207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTF67062Medicare UPIN