Healthcare Provider Details

I. General information

NPI: 1902161375
Provider Name (Legal Business Name): MITZY OHLIDAL MST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 07/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 MAIN STREET
WADDINGTON NY
13694-0249
US

IV. Provider business mailing address

PO BOX 249
WADDINGTON NY
13694-0249
US

V. Phone/Fax

Practice location:
  • Phone: 315-388-7703
  • Fax: 315-388-4707
Mailing address:
  • Phone: 315-388-7703
  • Fax: 315-388-4707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number470017931
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: