Provider Demographics
NPI:1396750857
Name:MITRA, AVICK G (MD)
Entity type:Individual
Prefix:DR
First Name:AVICK
Middle Name:G
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:PO BOX 601372
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1372
Mailing Address - Country:US
Mailing Address - Phone:704-355-3149
Mailing Address - Fax:704-355-5891
Practice Address - Street 1:1025 MOREHEAD MEDICAL DR
Practice Address - Street 2:SUITE 500, 5TH FLOOR
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2963
Practice Address - Country:US
Practice Address - Phone:704-355-3149
Practice Address - Fax:704-355-5891
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC32018207V00000X, 207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1396750857Medicaid
NC8959819Medicaid
SCN32018Medicaid
NC59819OtherBCBS NC
NC59819OtherBCBS NC
NCNCC9470193Medicare PIN
NC1396750857Medicaid
NC8959819Medicaid
NCP00303991Medicare PIN