Provider Demographics
NPI:1023000478
Name:MITRA, SUBIR K (MD)
Entity Type:Individual
Prefix:
First Name:SUBIR
Middle Name:K
Last Name:MITRA
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Mailing Address - Street 1:15650 N BLACK CANYON HWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85053-4064
Mailing Address - Country:US
Mailing Address - Phone:602-866-0550
Mailing Address - Fax:602-993-5788
Practice Address - Street 1:2030 W WHISPERING WIND DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85085-2853
Practice Address - Country:US
Practice Address - Phone:602-866-0550
Practice Address - Fax:602-993-5788
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2009-12-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ28970208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ567670Medicaid
AZZ133579Medicare PIN