Provider Demographics
NPI:1275851768
Name:MITTAL, JAY (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:
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 1:295 STONER AVE
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21157-5698
Mailing Address - Country:US
Mailing Address - Phone:410-871-6864
Mailing Address - Fax:410-871-6325
Practice Address - Street 1:295 STONER AVE STE 102
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-5662
Practice Address - Country:US
Practice Address - Phone:410-848-1818
Practice Address - Fax:410-848-1256
Is Sole Proprietor?:No
Enumeration Date:2010-05-10
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT197069208600000X, 390200000X
OH57.020479390200000X
MDD0082611208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program