Provider Demographics
NPI:1326148289
Name:MITRA, DEVASHIS A (MD)
Entity Type:Individual
Prefix:
First Name:DEVASHIS
Middle Name:A
Last Name:MITRA
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 1:5 LYN MAR PLZ
Mailing Address - Street 2:
Mailing Address - City:LYNDORA
Mailing Address - State:PA
Mailing Address - Zip Code:16045-1348
Mailing Address - Country:US
Mailing Address - Phone:724-282-5244
Mailing Address - Fax:724-282-5246
Practice Address - Street 1:5 LYN MAR PLAZA
Practice Address - Street 2:
Practice Address - City:LYNDORA
Practice Address - State:PA
Practice Address - Zip Code:16045-1348
Practice Address - Country:US
Practice Address - Phone:724-282-5244
Practice Address - Fax:724-282-5246
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD070008L207RR0500X
FLME165432207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
035360Medicare ID - Type Unspecified
H10902Medicare UPIN