Provider Demographics
NPI:1124049226
Name:MITRA, RAGHU (MD)
Entity type:Individual
Prefix:
First Name:RAGHU
Middle Name:
Last Name:MITRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 WINCHESTER DR
Mailing Address - Street 2:
Mailing Address - City:GLEN HEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11545-3203
Mailing Address - Country:US
Mailing Address - Phone:516-626-7780
Mailing Address - Fax:
Practice Address - Street 1:55 HORIZON DR
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-4436
Practice Address - Country:US
Practice Address - Phone:631-920-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2008-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY119844-12084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY89K301Medicare PIN