Provider Demographics
NPI:1215916200
Name:MITTAL, POOJA C (DO)
Entity type:Individual
Prefix:
First Name:POOJA
Middle Name:C
Last Name:MITTAL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 POTRERO AVENUE
Mailing Address - Street 2:BUILDING 80 WARD 83
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110
Mailing Address - Country:US
Mailing Address - Phone:415-443-6810
Mailing Address - Fax:415-443-8387
Practice Address - Street 1:955 POTRERO AVE
Practice Address - Street 2:BUILDING 80 WARD 83
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110
Practice Address - Country:US
Practice Address - Phone:415-443-6810
Practice Address - Fax:415-443-8387
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA225413207Q00000X
CA20A8712207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2107953Medicaid
MAI31892Medicare UPIN
MA2107953Medicaid