Provider Demographics
NPI:1720271760
Name:MISTRY, NITI (OD)
Entity Type:Individual
Prefix:
First Name:NITI
Middle Name:
Last Name:MISTRY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11103 WEST AVE
Mailing Address - Street 2:6
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-1370
Mailing Address - Country:US
Mailing Address - Phone:210-524-6509
Mailing Address - Fax:210-524-6587
Practice Address - Street 1:1255 BROAD ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-3000
Practice Address - Country:US
Practice Address - Phone:973-338-7575
Practice Address - Fax:973-338-5158
Is Sole Proprietor?:No
Enumeration Date:2007-08-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00584800152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ119098CQTMedicare PIN