Provider Demographics
NPI:1881977528
Name:MITNIK, ELLIOTT ILYA (DO)
Entity type:Individual
Prefix:DR
First Name:ELLIOTT
Middle Name:ILYA
Last Name:MITNIK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3620 BEDFORD AVE APT C9
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-5212
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 WASHINGTON RD
Practice Address - Street 2:CREDENTIALS OFFICE, KELLER ARMY COMMUNITY HOSPITAL
Practice Address - City:WEST POINT
Practice Address - State:NY
Practice Address - Zip Code:10996-1109
Practice Address - Country:US
Practice Address - Phone:646-327-5476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY260547 - 1208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY33025FOtherUPIN NUMBER IS VAD000