Healthcare Provider Details

I. General information

NPI: 1881045748
Provider Name (Legal Business Name): PETER NATHANAEL MITTWEDE M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2016
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 BAPTIST DR STE 301
MADISON MS
39110-2012
US

IV. Provider business mailing address

965 RIDGE LAKE BLVD STE 315
MEMPHIS TN
38120-9401
US

V. Phone/Fax

Practice location:
  • Phone: 601-973-1571
  • Fax: 601-973-1577
Mailing address:
  • Phone: 877-348-1281
  • Fax: 901-227-3206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD469401
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: