Provider Demographics
NPI:1255381752
Name:MITORAJ, THOMAS E (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:E
Last Name:MITORAJ
Suffix:
Gender:
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 632476
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-2476
Mailing Address - Country:US
Mailing Address - Phone:423-968-4007
Mailing Address - Fax:423-652-2590
Practice Address - Street 1:109 MEADOW VIEW RD
Practice Address - Street 2:STE 3
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-1661
Practice Address - Country:US
Practice Address - Phone:423-968-4007
Practice Address - Fax:423-652-2590
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN021345208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN123498OtherBLUE CROSS TN
VA006746080Medicaid
VA042029OtherANTHEM
TN3060577Medicaid