Provider Demographics
NPI:1447296538
Name:MITTAL, DEEPAK (MD)
Entity type:Individual
Prefix:MR
First Name:DEEPAK
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 1:47 CAVALIER BLVD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-3969
Mailing Address - Country:US
Mailing Address - Phone:859-757-4353
Mailing Address - Fax:859-534-0865
Practice Address - Street 1:47 CAVALIER BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-3969
Practice Address - Country:US
Practice Address - Phone:859-757-4353
Practice Address - Fax:859-534-0865
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY34456207R00000X, 207RN0300X
OH35.079382207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2275210Medicaid
KY64344559Medicaid
OHMI4113662Medicare PIN
KY00379001Medicare PIN
OH2275210Medicaid
KY0609067Medicare PIN
G85517Medicare UPIN