Provider Demographics
NPI:1871591610
Name:BREIDBART, MITCHELL J (DPM)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:J
Last Name:BREIDBART
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 1:724 166TH ST 9A
Mailing Address - Street 2:
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357-2036
Mailing Address - Country:US
Mailing Address - Phone:718-746-7704
Mailing Address - Fax:
Practice Address - Street 1:724 166TH ST 9A
Practice Address - Street 2:
Practice Address - City:WHITESTONE
Practice Address - State:NY
Practice Address - Zip Code:11357-2036
Practice Address - Country:US
Practice Address - Phone:718-746-7704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN003703213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00869732Medicaid
480004261Medicare PIN
NY60803Medicare PIN
NYT32030Medicare UPIN
NYP38651Medicare PIN