Healthcare Provider Details

I. General information

NPI: 1790736312
Provider Name (Legal Business Name): MICHELE A MITTELBRONN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 09/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 LAKE HUNTER CIR SUITE B
MT PLEASANT SC
29464-5427
US

IV. Provider business mailing address

999 LAKE HUNTER CIR SUITE B
MT PLEASANT SC
29464-5427
US

V. Phone/Fax

Practice location:
  • Phone: 843-881-2265
  • Fax: 843-881-2789
Mailing address:
  • Phone: 843-881-2265
  • Fax: 843-881-2789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number22838
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number22838
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number22838
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: