Basic Information
Provider Information | |||||||||
NPI: | 1033484241 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MITTAL | ||||||||
FirstName: | JYOTI | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MITTAL | ||||||||
OtherFirstName: | JUDY | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PAC | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 100 MILL PLAIN RD | ||||||||
Address2: |   | ||||||||
City: | DANBURY | ||||||||
State: | CT | ||||||||
PostalCode: | 068115178 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8609866440 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 604 CONTINENTAL BLVD | ||||||||
Address2: |   | ||||||||
City: | DANVILLE | ||||||||
State: | PA | ||||||||
PostalCode: | 178211022 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5702844575 | ||||||||
FaxNumber: | 5702454577 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/21/2012 | ||||||||
LastUpdateDate: | 08/08/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | MA055415 | PA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363AM0700X | 002965 | CT | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.