Provider Demographics
NPI:1508865973
Name:MITTAL, SHAMA RAVI (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAMA
Middle Name:RAVI
Last Name:MITTAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14816 PHYSICIANS LN
Mailing Address - Street 2:SUITE 152
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-3944
Mailing Address - Country:US
Mailing Address - Phone:240-453-0000
Mailing Address - Fax:301-591-4407
Practice Address - Street 1:14816 PHYSICIANS LN
Practice Address - Street 2:SUITE 152
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3944
Practice Address - Country:US
Practice Address - Phone:240-453-0000
Practice Address - Fax:301-591-4407
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-19
Last Update Date:2007-07-09
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-23
Provider Licenses
StateLicense IDTaxonomies
MDD061382207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD002542700Medicaid
MDG01826A01Medicare PIN