Provider Demographics
NPI:1669663217
Name:MAHAMITRA, NIRANDRA (MD)
Entity Type:Individual
Prefix:
First Name:NIRANDRA
Middle Name:
Last Name:MAHAMITRA
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 1:1 FEDERAL ST # 200
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-1088
Mailing Address - Country:US
Mailing Address - Phone:856-356-4924
Mailing Address - Fax:
Practice Address - Street 1:504 WHITE HORSE PIKE
Practice Address - Street 2:
Practice Address - City:HADDON HEIGHTS
Practice Address - State:NJ
Practice Address - Zip Code:08035
Practice Address - Country:US
Practice Address - Phone:856-546-7990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-08
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA082818207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00428381OtherRR MEDICARE
2861061000OtherAMERIHEALTH, KEYSTONE, IBC
NJ0141569Medicaid
010046054OtherAMERICHOICE
NJMA082818OtherNJ MEDICAL LICENSE
1635355OtherAETNA
6483065OtherCIGNA
NJ115416 DR8Medicare PIN