Provider Demographics
NPI:1538178736
Name:MITNIK, MICHAEL SUMNER (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SUMNER
Last Name:MITNIK
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:4801 MCMAHON BLVD NW SUITE 155
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114
Mailing Address - Country:US
Mailing Address - Phone:505-893-2880
Mailing Address - Fax:505-893-2886
Practice Address - Street 1:4801 MCMAHON BLVD NW SUITE 155
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114
Practice Address - Country:US
Practice Address - Phone:505-893-2880
Practice Address - Fax:505-893-2886
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NMNM84223207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM33589Medicaid
NM2124384Medicare ID - Type Unspecified
NM33589Medicaid