Provider Demographics
NPI:1053009597
Name:MITTAL, VIVEK (MD)
Entity type:Individual
Prefix:
First Name:VIVEK
Middle Name:
Last Name:MITTAL
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 1:44405 WOODWARD AVENUE
Mailing Address - Street 2:SUITE NUMBER; H-23
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:44405 WOODWARD AVENUE
Practice Address - Street 2:SUITE NUMBER; H-23
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341
Practice Address - Country:US
Practice Address - Phone:248-858-6233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-24
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program