Provider Demographics
NPI:1093894057
Name:MITRE, ISAAC N (MD)
Entity Type:Individual
Prefix:
First Name:ISAAC
Middle Name:N
Last Name:MITRE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1623 N 4TH STREET
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47804
Mailing Address - Country:US
Mailing Address - Phone:812-238-1652
Mailing Address - Fax:812-238-2648
Practice Address - Street 1:1623 N 4TH STREET
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47804
Practice Address - Country:US
Practice Address - Phone:812-238-1652
Practice Address - Fax:812-238-2648
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01022272A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100250040AMedicaid
000000082864OtherBC BS
IN100250040AMedicaid
000000082864OtherBC BS