Provider Demographics
NPI:1114068467
Name:MITRA, DEEPAK (MD)
Entity Type:Individual
Prefix:
First Name:DEEPAK
Middle Name:
Last Name:MITRA
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 1:633 RIDGEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-7012
Mailing Address - Country:US
Mailing Address - Phone:815-344-2760
Mailing Address - Fax:815-344-0664
Practice Address - Street 1:633 RIDGEVIEW DR
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-7012
Practice Address - Country:US
Practice Address - Phone:815-344-2760
Practice Address - Fax:815-344-0664
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN49813207R00000X
IL036-122249207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN552920000Medicaid
WIMITRADEEOtherMERCYCARE INSURANCE
ILP00684628CG6042OtherRR MEDICARE
IL214660006Medicare PIN
MN110011322Medicare PIN