1396709333 NPI number — DR. PREM P MITTAR MD

Table of content: DR. PREM P MITTAR MD (NPI 1396709333)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396709333 NPI number — DR. PREM P MITTAR MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MITTAR
Provider First Name:
PREM
Provider Middle Name:
P
Provider Name Prefix Text:
DR.
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:
1396709333
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3202 GLOUCHESTER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FALLSTON
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21047-1245
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-642-2411
Provider Business Mailing Address Fax Number:
410-642-1825

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
VA.MEDICAL CENTER
Provider Second Line Business Practice Location Address:
CIRCLE DRIVE
Provider Business Practice Location Address City Name:
PERRYPOINT
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-642-2411
Provider Business Practice Location Address Fax Number:
410-642-1825
Provider Enumeration Date:
04/14/2006

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:  D0043825 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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