Provider Demographics
NPI:1770740649
Name:MITTAL, KRITI (MD)
Entity type:Individual
Prefix:
First Name:KRITI
Middle Name:
Last Name:MITTAL
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:PO BOX 515348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:774-334-3550
Practice Address - Fax:774-442-9130
Is Sole Proprietor?:No
Enumeration Date:2008-05-19
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA233272207R00000X
MA244896207RH0003X
RIMD14675207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110086307AMedicaid