Provider Demographics
NPI:1679064851
Name:MITTAL, AMIT (MD)
Entity type:Individual
Prefix:
First Name:AMIT
Middle Name:
Last Name:MITTAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15655 37TH AVE N STE 100
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55446-4003
Mailing Address - Country:US
Mailing Address - Phone:630-632-2648
Mailing Address - Fax:612-230-8769
Practice Address - Street 1:15655 37TH AVE N STE 100
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55446-4003
Practice Address - Country:US
Practice Address - Phone:630-632-2648
Practice Address - Fax:612-230-8769
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN66152207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology