Healthcare Provider Details

I. General information

NPI: 1528269388
Provider Name (Legal Business Name): MIKHAIL ITINGEN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

68 HARRIS BUSHVILLE RD
HARRIS NY
12742-1000
US

IV. Provider business mailing address

68 HARRIS BUSHVILLE RD
HARRIS NY
12742-1000
US

V. Phone/Fax

Practice location:
  • Phone: 845-794-0996
  • Fax: 845-794-3347
Mailing address:
  • Phone: 845-794-0996
  • Fax: 845-794-3347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberOS015048
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number245080
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: