Provider Demographics
NPI:1962434712
Name:MUTCH, ROBERT G (DO)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:G
Last Name:MUTCH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:661 E ALTAMONTE DR STE 328
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-5103
Mailing Address - Country:US
Mailing Address - Phone:407-303-5204
Mailing Address - Fax:407-303-5205
Practice Address - Street 1:661 E ALTAMONTE DR STE 328
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701
Practice Address - Country:US
Practice Address - Phone:407-303-5204
Practice Address - Fax:407-303-5205
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS16256207V00000X
MI5101013139207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4531773Medicaid
MI4568586Medicaid
MI4831808Medicaid
H43048Medicare UPIN
0N87150Medicare ID - Type Unspecified