Provider Demographics
NPI:1285637694
Name:MITAL, CHETNA
Entity Type:Individual
Prefix:
First Name:CHETNA
Middle Name:
Last Name:MITAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 CEREAL AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45013-2776
Mailing Address - Country:US
Mailing Address - Phone:513-867-2622
Mailing Address - Fax:513-867-2093
Practice Address - Street 1:1010 CEREAL AVE
Practice Address - Street 2:STE 307
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45013
Practice Address - Country:US
Practice Address - Phone:513-867-2622
Practice Address - Fax:513-867-2093
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-053073207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0660520Medicaid
OH0660520Medicaid
OHMI0605085Medicare ID - Type Unspecified