Provider Demographics
NPI:1629038377
Name:MITTAL, VIKAS SIMON (MD)
Entity Type:Individual
Prefix:
First Name:VIKAS
Middle Name:SIMON
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 1:1675 VILLAGE TRL E
Mailing Address - Street 2:UNIT # 6
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-5819
Mailing Address - Country:US
Mailing Address - Phone:507-363-9367
Mailing Address - Fax:
Practice Address - Street 1:7801 E BUSH LAKE RD STE 400
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55439-3113
Practice Address - Country:US
Practice Address - Phone:507-363-9367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-26
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN42701207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN764422100Medicaid
H23581Medicare UPIN
110006789Medicare ID - Type Unspecified