Provider Demographics
NPI:1124266366
Name:MITRA, TITHI (MD)
Entity type:Individual
Prefix:DR
First Name:TITHI
Middle Name:
Last Name:MITRA
Suffix:
Gender:F
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:PO BOX 8000
Mailing Address - Street 2:DEPT 596
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14267-0002
Mailing Address - Country:US
Mailing Address - Phone:866-295-0041
Mailing Address - Fax:732-557-7109
Practice Address - Street 1:368 LAKEHURST RD
Practice Address - Street 2:SUITE 207
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-7339
Practice Address - Country:US
Practice Address - Phone:732-557-6222
Practice Address - Fax:732-557-6227
Is Sole Proprietor?:No
Enumeration Date:2009-01-26
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09322600207R00000X
NY267178207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03512810Medicaid
NJ0386146Medicaid
NYA400078635Medicare PIN