Provider Demographics
NPI:1760534424
Name:MITTAL, MANISHA (MD)
Entity Type:Individual
Prefix:MS
First Name:MANISHA
Middle Name:
Last Name:MITTAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 ALLUMBAUGH ST
Mailing Address - Street 2:STE 101
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9212
Mailing Address - Country:US
Mailing Address - Phone:208-323-1125
Mailing Address - Fax:208-323-9604
Practice Address - Street 1:413 ALLUMBAUGH ST
Practice Address - Street 2:STE 101
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9212
Practice Address - Country:US
Practice Address - Phone:208-323-1125
Practice Address - Fax:208-323-9604
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7355207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1139542Medicare PIN
ID1139542Medicare ID - Type Unspecified
IDG75161Medicare UPIN