Provider Demographics
NPI:1972520708
Name:MITTAL, MANOJ (MD)
Entity Type:Individual
Prefix:
First Name:MANOJ
Middle Name:
Last Name:MITTAL
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 1:2001 W ORANGE GROVE RD
Mailing Address - Street 2:STE 510
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-1139
Mailing Address - Country:US
Mailing Address - Phone:520-219-1539
Mailing Address - Fax:520-797-6704
Practice Address - Street 1:2001 W ORANGE GROVE RD
Practice Address - Street 2:STE 510
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-1139
Practice Address - Country:US
Practice Address - Phone:520-219-1539
Practice Address - Fax:520-797-6704
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ29007207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ695744Medicaid
AZ69997Medicare ID - Type Unspecified
AZ695744Medicaid