Provider Demographics
NPI:1710097456
Name:MITRA, MONALISA M (DO)
Entity Type:Individual
Prefix:
First Name:MONALISA
Middle Name:M
Last Name:MITRA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4100 HERITAGE AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-5716
Mailing Address - Country:US
Mailing Address - Phone:817-283-1112
Mailing Address - Fax:817-283-1116
Practice Address - Street 1:4100 HERITAGE AVE
Practice Address - Street 2:STE 106
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-5714
Practice Address - Country:US
Practice Address - Phone:817-283-1112
Practice Address - Fax:817-283-1116
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXM4363207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX184283303Medicaid
TX184283302Medicaid
TX8K6216Medicare PIN
TX184283302Medicaid
TX184283303Medicaid