Basic Information
| Provider Information | |||||||||
| NPI: | 1255402137 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MITTLEMAN | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | S. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 393 E WALNUT ST | ||||||||
| Address2: | 3RD FLOOR PHR SYSTEMS | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911880001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264053640 | ||||||||
| FaxNumber: | 6264056768 | ||||||||
| Practice Location | |||||||||
| Address1: | 1011 BALDWIN PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | BALDWIN PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917065806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6268511011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | G17274 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 00G172740 | 05 | CA | MEDICAID |