1619948213 NPI number — SAMUEL R MITZ MD

Table of content: SAMUEL R MITZ MD (NPI 1619948213)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619948213 NPI number — SAMUEL R MITZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MITZ
Provider First Name:
SAMUEL
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619948213
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 92
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHANNON
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35142-0092
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1664 SYLVAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75208-2543
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-535-7079
Provider Business Practice Location Address Fax Number:
214-484-4111
Provider Enumeration Date:
01/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  L5468 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: 64904 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , with the licence number: 14459 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 166418705 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 166418707 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0023RR . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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