Provider Demographics
NPI:1538234414
Name:MITTLEIDER, DEREK (MD)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:MITTLEIDER
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 1:2300 STATE ROAD 524 STE 106
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32926-5894
Mailing Address - Country:US
Mailing Address - Phone:321-321-3001
Mailing Address - Fax:321-321-4001
Practice Address - Street 1:2300 STATE ROAD 524 STE 106
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32926-5894
Practice Address - Country:US
Practice Address - Phone:321-321-3001
Practice Address - Fax:321-321-4001
Is Sole Proprietor?:No
Enumeration Date:2006-11-23
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1421522085R0202X
FLME141522085R0204X, 2085R0204X
MEMD185482085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology