Provider Demographics
NPI:1154879195
Name:RAJ A. MITTAL, M.D., A MEDICAL CORPORATION
Entity type:Organization
Organization Name:RAJ A. MITTAL, M.D., A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAJ
Authorized Official - Middle Name:A
Authorized Official - Last Name:MITTAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-483-5411
Mailing Address - Street 1:868 VIA DEL MONTE
Mailing Address - Street 2:
Mailing Address - City:PALOS VERDES ESTATES
Mailing Address - State:CA
Mailing Address - Zip Code:90274-1664
Mailing Address - Country:US
Mailing Address - Phone:310-483-5411
Mailing Address - Fax:844-704-5739
Practice Address - Street 1:868 VIA DEL MONTE
Practice Address - Street 2:
Practice Address - City:PALOS VERDES ESTATES
Practice Address - State:CA
Practice Address - Zip Code:90274-1664
Practice Address - Country:US
Practice Address - Phone:310-483-5411
Practice Address - Fax:844-704-5739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-20
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA123128208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1356541338OtherINDIVIDUAL MEDICARE NPI