Healthcare Provider Details

I. General information

NPI: 1710087408
Provider Name (Legal Business Name): LAWRENCE OTTO MIETZELFELD JR. D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 S MAIN ST
ONEONTA NY
13820-2516
US

IV. Provider business mailing address

55 S MAIN ST
ONEONTA NY
13820-2516
US

V. Phone/Fax

Practice location:
  • Phone: 607-432-4330
  • Fax:
Mailing address:
  • Phone: 607-432-4330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberX003096
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: