Provider Demographics
NPI:1467437079
Name:MITRA, SHYAMAL K (MD)
Entity Type:Individual
Prefix:DR
First Name:SHYAMAL
Middle Name:K
Last Name:MITRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3280 HENDERSON DR STE C
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-5290
Mailing Address - Country:US
Mailing Address - Phone:910-915-8450
Mailing Address - Fax:888-745-7026
Practice Address - Street 1:3280 HENDERSON DR STE C
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-5290
Practice Address - Country:US
Practice Address - Phone:910-915-8450
Practice Address - Fax:888-745-7026
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0035439207RC0000X, 207U00000X, 207UN0901X
NC00-35439207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC59825OtherBCBS OF NC
060030036OtherRAILROAD MEDICARE
NC8959825Medicaid
NC8959825Medicaid
E62936Medicare UPIN