Provider Demographics
NPI:1730163411
Name:MITNICK, PAUL D (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:D
Last Name:MITNICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:301 S 7TH AVE
Mailing Address - Street 2:STE 355
Mailing Address - City:WEST READING
Mailing Address - State:PA
Mailing Address - Zip Code:19611-1410
Mailing Address - Country:US
Mailing Address - Phone:610-376-7365
Mailing Address - Fax:610-376-1320
Practice Address - Street 1:301 S 7TH AVE
Practice Address - Street 2:STE 355
Practice Address - City:WEST READING
Practice Address - State:PA
Practice Address - Zip Code:19611-1410
Practice Address - Country:US
Practice Address - Phone:610-376-7365
Practice Address - Fax:610-376-1320
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2010-11-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAMD017057E207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006072380001Medicaid
PA0006072380001Medicaid
PAB35382Medicare UPIN