Healthcare Provider Details

I. General information

NPI: 1407016348
Provider Name (Legal Business Name): RONALD JOSEPH MITTEL JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2008
Last Update Date: 07/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13965 N 75TH AVE
PEORIA AZ
85381-6097
US

IV. Provider business mailing address

13965 N 75TH AVE
PEORIA AZ
85381-6097
US

V. Phone/Fax

Practice location:
  • Phone: 602-843-2991
  • Fax: 602-978-1226
Mailing address:
  • Phone: 602-843-2991
  • Fax: 602-978-1226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125054682
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number46987
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: