Provider Demographics
NPI:1336164359
Name:DALSANIA, MITAL PARAG (MD)
Entity Type:Individual
Prefix:
First Name:MITAL
Middle Name:PARAG
Last Name:DALSANIA
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 1:809 WANDERING WAY DR
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-7016
Mailing Address - Country:US
Mailing Address - Phone:704-843-8454
Mailing Address - Fax:
Practice Address - Street 1:1601 BRENNER AVE
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-2515
Practice Address - Country:US
Practice Address - Phone:704-638-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2006008002084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5904390Medicaid
SCN0080HMedicaid
NCNCA219AOtherMEDICARE PIN, INDIVIDUAL FOR CMC-NORTHEAST
NCI25096Medicare UPIN
SCN0080HMedicaid