Provider Demographics
NPI:1962548636
Name:MITAL, PRAVEEN K (MD)
Entity type:Individual
Prefix:
First Name:PRAVEEN
Middle Name:K
Last Name:MITAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:300 COMMUNITY DR
Mailing Address - Street 2:DEPARTMENT OF EMERGENCY MEDICINE
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-3816
Mailing Address - Country:US
Mailing Address - Phone:516-562-3090
Mailing Address - Fax:516-562-3680
Practice Address - Street 1:300 COMMUNITY DR
Practice Address - Street 2:DEPARTMENT OF EMERGENCY MEDICINE
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3816
Practice Address - Country:US
Practice Address - Phone:516-562-4125
Practice Address - Fax:516-562-3680
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMT184045207P00000X
DEC1-0008382207P00000X
NY273925207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1962548636Medicaid
DE022278D18Medicare PIN