Provider Demographics
NPI:1710944079
Name:MAITRA, SUBHASHIS
Entity Type:Individual
Prefix:
First Name:SUBHASHIS
Middle Name:
Last Name:MAITRA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 NINTH AVENUE
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602-2014
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2525 9TH AVE
Practice Address - Street 2:SUITE 1B
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602-2014
Practice Address - Country:US
Practice Address - Phone:814-942-6038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-037191-E2086S0129X
PAMD037191E208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1019567OtherGATEWAYHEALTHPLAN
PA0012795990005Medicaid
020040397OtherRAILROAD MEDICARE
020040397OtherRAILROAD MEDICARE
PAMA714254Medicare ID - Type Unspecified