Provider Demographics
NPI:1114399474
Name:ESMAEILI, MITTRA (DO)
Entity Type:Individual
Prefix:
First Name:MITTRA
Middle Name:
Last Name:ESMAEILI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1595
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-1595
Mailing Address - Country:US
Mailing Address - Phone:606-408-9571
Mailing Address - Fax:606-408-6061
Practice Address - Street 1:398 DIEDERICH BLVD
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-7008
Practice Address - Country:US
Practice Address - Phone:606-324-8060
Practice Address - Fax:606-325-6889
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-27
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH58.007308207Q00000X
KYTP870207Q00000X
KY04945207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100724840Medicaid
OH0331450Medicaid