Provider Demographics
NPI:1922263573
Name:KUNAL MITRA MD
Entity Type:Organization
Organization Name:KUNAL MITRA MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KUNAL
Authorized Official - Middle Name:
Authorized Official - Last Name:MITRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-725-7100
Mailing Address - Street 1:3575 RESERVE COMMONS DR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256
Mailing Address - Country:US
Mailing Address - Phone:330-725-7100
Mailing Address - Fax:330-725-3084
Practice Address - Street 1:3575 RESERVE COMMONS DR
Practice Address - Street 2:SUITE 150
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256
Practice Address - Country:US
Practice Address - Phone:330-725-7100
Practice Address - Fax:330-725-3084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-23
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35052774M207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0709559Medicaid
OHMI0615431Medicare PIN
OH0709559Medicaid