Provider Demographics
NPI:1083150221
Name:MITRA, ANIRBAN P (MD, PHD)
Entity Type:Individual
Prefix:
First Name:ANIRBAN
Middle Name:P
Last Name:MITRA
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 1:4140 W 190TH ST
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504-5513
Mailing Address - Country:US
Mailing Address - Phone:310-423-4700
Mailing Address - Fax:
Practice Address - Street 1:8635 W 3RD ST STE 1070W
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-6137
Practice Address - Country:US
Practice Address - Phone:310-423-4700
Practice Address - Fax:310-423-1886
Is Sole Proprietor?:No
Enumeration Date:2017-01-11
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS5994208800000X
CA152449208800000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX418026701Medicaid
TX418026702OtherCSHCN MEDICAID TPI