Provider Demographics
NPI:1366476319
Name:MITTAL, PRABHAS (MD)
Entity Type:Individual
Prefix:
First Name:PRABHAS
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 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:NEOPLASTIC DISEASES
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-6800
Mailing Address - Fax:414-805-0618
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:NEOPLASTIC DISEASES
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-6800
Practice Address - Fax:414-805-0618
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00041314207RX0202X
WI50320207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0164822OtherL&I
WI1366476319Medicaid
WA8331225Medicaid
WI680860590Medicare PIN
WA0164822OtherL&I
WAH74808Medicare UPIN
WA8331225Medicaid
WI680860590Medicare PIN
WI1366476319Medicaid