Provider Demographics
NPI:1245224518
Name:MITRA, SHIVANI (MD)
Entity Type:Individual
Prefix:
First Name:SHIVANI
Middle Name:
Last Name:MITRA
Suffix:
Gender:F
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 850001
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32885-0001
Mailing Address - Country:US
Mailing Address - Phone:321-268-6111
Mailing Address - Fax:321-268-0125
Practice Address - Street 1:5005 PORT ST JOHN PKWY
Practice Address - Street 2:2500
Practice Address - City:PORT ST JOHN
Practice Address - State:FL
Practice Address - Zip Code:32927-4305
Practice Address - Country:US
Practice Address - Phone:321-690-0164
Practice Address - Fax:321-690-2591
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME101697208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000036200Medicaid
FL000036200Medicaid