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General NPI Number Information
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NPI Number | 1881977528
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Entity Type | Individual
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Provider Name | ELLIOTT ILYA MITNIK D.O.
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Gender | Male
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Dates
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Enumeration Date | 09/20/2011
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Last Update Date | 09/20/2011
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Provider Practice Location Address
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Address Line | 900 WASHINGTON RD CREDENTIALS OFFICE, KELLER ARMY COMMUNITY HOSPITAL
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City | WEST POINT
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State | NY
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Zip | 10996-1109
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Country | US
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Telephone | 646-327-5476
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Fax |
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Provider Business Mailing Address
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Address Line | 3620 BEDFORD AVE APT C9
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City | BROOKLYN
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State | NY
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Zip | 11210-5212
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 260547 - 1
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License Number State | NY
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