Provider Demographics
NPI:1902894025
Name:MITTY, ROGER D (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:D
Last Name:MITTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 NEVINS ST
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-3514
Mailing Address - Country:US
Mailing Address - Phone:617-562-5432
Mailing Address - Fax:617-789-5049
Practice Address - Street 1:11 NEVINS ST
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-3514
Practice Address - Country:US
Practice Address - Phone:617-562-5432
Practice Address - Fax:617-789-5049
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY779172207R00000X
MA74173207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3125734Medicaid
F80490Medicare UPIN
MAJ30543Medicare ID - Type Unspecified