Healthcare Provider Details

I. General information

NPI: 1023060696
Provider Name (Legal Business Name): NICHOLAS M. MITTICA JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 11/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 W SPRING ST
SILVER CITY NM
88061-4847
US

IV. Provider business mailing address

604 W SPRING ST
SILVER CITY NM
88061-4847
US

V. Phone/Fax

Practice location:
  • Phone: 575-388-4464
  • Fax: 575-388-2014
Mailing address:
  • Phone: 575-388-4464
  • Fax: 575-388-2014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD2004-0317
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: