Provider Demographics
NPI:1134296718
Name:MITTAL, RAM K (MD)
Entity Type:Individual
Prefix:
First Name:RAM
Middle Name:K
Last Name:MITTAL
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:PO BOX 935
Mailing Address - Street 2:
Mailing Address - City:HALES CORNERS
Mailing Address - State:WI
Mailing Address - Zip Code:53130-0935
Mailing Address - Country:US
Mailing Address - Phone:414-762-3910
Mailing Address - Fax:414-762-9694
Practice Address - Street 1:100 15TH AVENUE
Practice Address - Street 2:SUIT 170
Practice Address - City:SOUTH MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53172
Practice Address - Country:US
Practice Address - Phone:414-762-3910
Practice Address - Fax:414-762-9694
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20701208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30152400Medicaid
000073556Medicare ID - Type Unspecified
WI30152400Medicaid