Healthcare Provider Details

I. General information

NPI: 1093790016
Provider Name (Legal Business Name): DAVID CHARLES MITTELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 04/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 WATERDAM PLAZA DR SUITE 180
MC MURRAY PA
15317-5412
US

IV. Provider business mailing address

5000 WATERDAM PLAZA DR SUITE 180
MC MURRAY PA
15317-5412
US

V. Phone/Fax

Practice location:
  • Phone: 724-942-4372
  • Fax: 724-942-4373
Mailing address:
  • Phone: 724-942-4372
  • Fax: 724-942-4373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD022476E
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0009586090002
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: