Healthcare Provider Details

I. General information

NPI: 1134435407
Provider Name (Legal Business Name): MICHAEL S. MITNIK, M.D.,PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2010
Last Update Date: 08/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 MCMAHON BLVD NW SUITE 155
ALBUQUERQUE NM
87114-5090
US

IV. Provider business mailing address

4801 MCMAHON BLVD NW SUITE 155
ALBUQUERQUE NM
87114-5090
US

V. Phone/Fax

Practice location:
  • Phone: 505-893-2880
  • Fax: 505-893-2886
Mailing address:
  • Phone: 505-893-2880
  • Fax: 505-893-2886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number84223
License Number StateNM

VIII. Authorized Official

Name: MICHAEL SUMNER MITNIK
Title or Position: PRESIDENT
Credential: M.D.
Phone: 505-893-2880