Provider Demographics
NPI:1356432264
Name:MITTA, SWAROOP (MD)
Entity type:Individual
Prefix:DR
First Name:SWAROOP
Middle Name:
Last Name:MITTA
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 1:403 PEBBLE CREEK LN
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330-8307
Mailing Address - Country:US
Mailing Address - Phone:985-626-6133
Mailing Address - Fax:
Practice Address - Street 1:33700 HWY 43
Practice Address - Street 2:SUITE B
Practice Address - City:THOMASVILLE
Practice Address - State:AL
Practice Address - Zip Code:36784-3555
Practice Address - Country:US
Practice Address - Phone:334-636-4431
Practice Address - Fax:334-636-6129
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00022410207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALH10729Medicare UPIN