Healthcare Provider Details

I. General information

NPI: 1407929375
Provider Name (Legal Business Name): AVERY C MITTMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 10/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1154 N EUCLID ST
ANAHEIM CA
92801-1955
US

IV. Provider business mailing address

PO BOX 2757
ORANGE CA
92859-0757
US

V. Phone/Fax

Practice location:
  • Phone: 714-635-6272
  • Fax:
Mailing address:
  • Phone: 714-973-2650
  • Fax: 714-973-2655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberG65682
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: