Basic Information
| Provider Information | |||||||||
| NPI: | 1114399474 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ESMAEILI | ||||||||
| FirstName: | MITTRA | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1595 | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411051595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064089571 | ||||||||
| FaxNumber: | 6064086061 | ||||||||
| Practice Location | |||||||||
| Address1: | 398 DIEDERICH BLVD | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411017008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063248060 | ||||||||
| FaxNumber: | 6063256889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2015 | ||||||||
| LastUpdateDate: | 05/20/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 58.007308 | OH | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | TP870 | KY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 04945 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7100724840 | 05 | KY | MEDICAID | 0331450 | 05 | OH | MEDICAID |