Provider Demographics
NPI:1073979233
Name:MITAL, INDU BALA (MD)
Entity Type:Individual
Prefix:
First Name:INDU
Middle Name:BALA
Last Name:MITAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:INDU
Other - Middle Name:
Other - Last Name:MITAL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:104 WOOD DUCK LN
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-7845
Mailing Address - Country:US
Mailing Address - Phone:248-535-2663
Mailing Address - Fax:
Practice Address - Street 1:104 WOOD DUCK LN
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-7845
Practice Address - Country:US
Practice Address - Phone:248-535-2663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-04
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301034393207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology