Provider Demographics
NPI:1760625552
Name:MISTRY, SIMA GOPAL (MD)
Entity Type:Individual
Prefix:
First Name:SIMA
Middle Name:GOPAL
Last Name:MISTRY
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:PO BOX 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:866-366-2983
Mailing Address - Fax:
Practice Address - Street 1:11603 STATE AVE STE G
Practice Address - Street 2:PROVIDENCE MEDICAL GROUP MARYSVILLE CLINIC
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98271-8465
Practice Address - Country:US
Practice Address - Phone:360-658-6800
Practice Address - Fax:360-658-6819
Is Sole Proprietor?:No
Enumeration Date:2009-04-09
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60403767208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1926710Medicaid
WAMD60403767OtherWSL
WAG8922842Medicare PIN