Provider Demographics
NPI:1285950469
Name:MITRA, SANJAY (MD)
Entity type:Individual
Prefix:
First Name:SANJAY
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 1:4800 FRIENDSHIP AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15224-1722
Mailing Address - Country:US
Mailing Address - Phone:412-578-5858
Mailing Address - Fax:412-330-1529
Practice Address - Street 1:4800 FRIENDSHIP AVE FL 3
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15224-1722
Practice Address - Country:US
Practice Address - Phone:412-578-5858
Practice Address - Fax:412-330-1529
Is Sole Proprietor?:No
Enumeration Date:2010-04-13
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV23965208000000X, 2080N0001X
PAMD4569832080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102501240Medicaid
WV3810017874Medicaid
WV3810017874Medicaid