Provider Demographics
NPI:1528062221
Name:MITRA, RAMAN L (MD)
Entity type:Individual
Prefix:DR
First Name:RAMAN
Middle Name:L
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 1:610 N MICHIGAN ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-1077
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:610 N MICHIGAN ST
Practice Address - Street 2:SUITE 400
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1077
Practice Address - Country:US
Practice Address - Phone:574-647-8120
Practice Address - Fax:574-647-8111
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01045628A207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200102610Medicaid
F31643Medicare UPIN