Provider Demographics
NPI:1558427377
Name:MITTAL, BASANT KUMAR (MD)
Entity Type:Individual
Prefix:
First Name:BASANT
Middle Name:KUMAR
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 1:511 PIERCE ST
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-5731
Mailing Address - Country:US
Mailing Address - Phone:570-243-3300
Mailing Address - Fax:570-338-3993
Practice Address - Street 1:511 PIERCE ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-5731
Practice Address - Country:US
Practice Address - Phone:570-243-3300
Practice Address - Fax:570-338-3993
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-039080-L208000000X, 207R00000X
PAMD039080L208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102576296Medicaid
PAMI 68463Medicare ID - Type Unspecified