Provider Demographics
NPI:1215945282
Name:MITTLEMAN, HENRY LAWRANCE (DPM)
Entity type:Individual
Prefix:DR
First Name:HENRY
Middle Name:LAWRANCE
Last Name:MITTLEMAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6821 MONTGOMERY NE
Mailing Address - Street 2:STE D
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-1444
Mailing Address - Country:US
Mailing Address - Phone:505-881-8081
Mailing Address - Fax:
Practice Address - Street 1:6821 MONTGOMERY NE
Practice Address - Street 2:STE D
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1444
Practice Address - Country:US
Practice Address - Phone:505-881-8081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM98213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM53231Medicaid
NM53231Medicaid
41086Medicare UPIN