Healthcare Provider Details

I. General information

NPI: 1649390964
Provider Name (Legal Business Name): RICHARD ANDREW MITSAK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 NEIL AVE ROOM 438
COLUMBUS OH
43201
US

IV. Provider business mailing address

PO BOX 130 13311 EAST BUCK RUN RD
ROCKBRIDGE OH
43149-0130
US

V. Phone/Fax

Practice location:
  • Phone: 614-292-5766
  • Fax: 614-688-3440
Mailing address:
  • Phone: 740-385-6342
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberOHIO3533704
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: