Provider Demographics
NPI:1285064196
Name:MITTAPALLI OBGYN PLLC
Entity type:Organization
Organization Name:MITTAPALLI OBGYN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAJA
Authorized Official - Middle Name:
Authorized Official - Last Name:MITTAPALLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-206-9752
Mailing Address - Street 1:PO BOX 8430
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS
Mailing Address - State:AZ
Mailing Address - Zip Code:85349-6828
Mailing Address - Country:US
Mailing Address - Phone:928-627-5678
Mailing Address - Fax:928-627-5677
Practice Address - Street 1:845 E. B STREET
Practice Address - Street 2:
Practice Address - City:SAN LUIS
Practice Address - State:AZ
Practice Address - Zip Code:85349
Practice Address - Country:US
Practice Address - Phone:928-627-5678
Practice Address - Fax:928-627-5677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-14
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ36264207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ114585Medicare PIN