Provider Demographics
NPI:1689603102
Name:MITTAL, SANJEEV KUMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:SANJEEV
Middle Name:KUMAR
Last Name:MITTAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6027 WALNUT GROVE RD
Mailing Address - Street 2:402
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2145
Mailing Address - Country:US
Mailing Address - Phone:901-767-0304
Mailing Address - Fax:901-767-0304
Practice Address - Street 1:6027 WALNUT GROVE RD STE 402
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2129
Practice Address - Country:US
Practice Address - Phone:901-767-0304
Practice Address - Fax:901-767-3884
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD32232207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3857927Medicare ID - Type UnspecifiedPROVIDER NUMBER
TNH27358Medicare UPIN