Provider Demographics
NPI:1063819951
Name:SHAH BHAGAT, MITA
Entity Type:Individual
Prefix:
First Name:MITA
Middle Name:
Last Name:SHAH BHAGAT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13175 FOX HUNT LN
Mailing Address - Street 2:163
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-5389
Mailing Address - Country:US
Mailing Address - Phone:908-922-3743
Mailing Address - Fax:
Practice Address - Street 1:13175 FOX HUNT LN
Practice Address - Street 2:163
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20171-5389
Practice Address - Country:US
Practice Address - Phone:908-922-3743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-20
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education