Provider Demographics
NPI:1720024219
Name:MITAL, DEEPAK (MD)
Entity Type:Individual
Prefix:
First Name:DEEPAK
Middle Name:
Last Name:MITAL
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 1:29373 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1293
Mailing Address - Country:US
Mailing Address - Phone:847-390-5900
Mailing Address - Fax:
Practice Address - Street 1:4400 W 95TH ST STE 112
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2657
Practice Address - Country:US
Practice Address - Phone:708-684-7100
Practice Address - Fax:708-684-7130
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-087116204F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF79841Medicare UPIN
ILL84365Medicare ID - Type Unspecified