1114068467 NPI number — DEEPAK MITRA MD

Table of content: DEEPAK MITRA MD (NPI 1114068467)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114068467 NPI number — DEEPAK MITRA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MITRA
Provider First Name:
DEEPAK
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114068467
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
633 RIDGEVIEW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCHENRY
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60050-7012
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-344-2760
Provider Business Mailing Address Fax Number:
815-344-0664

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
633 RIDGEVIEW DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCHENRY
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60050-7012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-344-2760
Provider Business Practice Location Address Fax Number:
815-344-0664
Provider Enumeration Date:
02/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  49813 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 036-122249 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 552920000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: MITRADEE . This is a "MERCYCARE INSURANCE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: P00684628CG6042 . This is a "RR MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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