Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207R00000X | Internist | T2009005450 | MO |
N | 111NI0900X | Internist | T2009005450 | MO |
N | 207RC0000X | Internist - Cardiovascular Disease | 01078863A | IN |
N | 207RC0000X | Internist - Cardiovascular Disease | 4301109220 | MI |
Y | 207RI0011X | Interventional Cardiology | 01078863A | IN |
NPI | 1003044702 |
---|---|
Provider Name | Mayank Kumar Mittal |
First Address | South Bend, IN 46617-1924 |
Second Address | South Bend, IN 46601 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/07/2009 |
Last Update Date | 31/03/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
257270011 | MEDICARE PTAN (01) | IN |
300004379 | (05) | IN |
565800028 | MEDICARE PTAN (01) | IN |