Provider Demographics
NPI:1003044702
Name:MITTAL, MAYANK KUMAR (MD)
Entity Type:Individual
Prefix:
First Name:MAYANK
Middle Name:KUMAR
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 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:574-647-2129
Mailing Address - Fax:574-237-6069
Practice Address - Street 1:610 N MICHIGAN ST STE 400
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601
Practice Address - Country:US
Practice Address - Phone:574-647-8120
Practice Address - Fax:574-647-8111
Is Sole Proprietor?:No
Enumeration Date:2009-07-01
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT2009005450207R00000X
MI4301109220207RC0000X
IN01078863A207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300004379Medicaid
IN300004379Medicaid
IN565800028OtherMEDICARE PTAN