Provider Demographics
NPI:1023046562
Name:MITTAL, RAKESH (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:RAKESH
Middle Name:
Last Name:MITTAL
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5880 49TH ST N
Mailing Address - Street 2:SUITE N105
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33709-2150
Mailing Address - Country:US
Mailing Address - Phone:727-527-0797
Mailing Address - Fax:727-528-7703
Practice Address - Street 1:5880 49TH ST N
Practice Address - Street 2:SUITE N105
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33709-2150
Practice Address - Country:US
Practice Address - Phone:727-527-0797
Practice Address - Fax:727-528-7703
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0073653207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL253504100Medicaid
FLG62182Medicare UPIN
FL44246AMedicare ID - Type Unspecified