Provider Demographics
NPI:1649293515
Name:MITTLEMAN, FREDERICK STUART (MD)
Entity type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:STUART
Last Name:MITTLEMAN
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 1:127 NORTH FIFTH AVE.
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85701
Mailing Address - Country:US
Mailing Address - Phone:520-202-1758
Mailing Address - Fax:520-882-0528
Practice Address - Street 1:127 S 5TH AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85701-2005
Practice Address - Country:US
Practice Address - Phone:520-202-1888
Practice Address - Fax:520-202-1889
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-152842084P0800X
MOR2C292084P0800X
NE122292084P0800X
CO227302084P0800X
MDD137932084P0800X
VA01010221302084P0800X
CT0367622084P0800X
AZ360802084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS610289OtherBLUE SHIELD OF KANSAS
MO09752017OtherBLUE SHIELD OF KC
662060001OtherTRICARE
KS0006026BMedicare ID - Type Unspecified
662060001OtherTRICARE