Provider Demographics
NPI:1588648851
Name:MISTRY, PRAMOD K (MBBS PHD)
Entity Type:Individual
Prefix:
First Name:PRAMOD
Middle Name:K
Last Name:MISTRY
Suffix:
Gender:M
Credentials:MBBS PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 CEDAR ST
Mailing Address - Street 2:LMP 1080
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3206
Mailing Address - Country:US
Mailing Address - Phone:203-785-7352
Mailing Address - Fax:203-785-7273
Practice Address - Street 1:800 HOWARD AVE
Practice Address - Street 2:YALE PHYSICIANS BLDG, 4TH FL
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1369
Practice Address - Country:US
Practice Address - Phone:203-785-7352
Practice Address - Fax:203-785-7273
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT039656207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001396565Medicaid
CT100000328Medicare ID - Type Unspecified
H07531Medicare UPIN