Provider Demographics
NPI:1699841247
Name:MITRA, PRODYOT KUMAR (MD)
Entity Type:Individual
Prefix:MR
First Name:PRODYOT
Middle Name:KUMAR
Last Name:MITRA
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 1:633 RIDGEVIEW DRIVE
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-7012
Mailing Address - Country:US
Mailing Address - Phone:815-344-0621
Mailing Address - Fax:815-344-0664
Practice Address - Street 1:633 RIDGEVIEW DRIVE
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-7012
Practice Address - Country:US
Practice Address - Phone:815-344-0621
Practice Address - Fax:815-344-0664
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036052608208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL024000852OtherRAILROAD MEDICARE
IL05600205OtherBLUE CROSS BLUE SHIELD
IL5432896OtherCIGNA
IL0360526081Medicaid
IL024000852OtherRAILROAD MEDICARE
IL5432896OtherCIGNA