Basic Information
| Provider Information | |||||||||
| NPI: | 1245224518 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MITRA | ||||||||
| FirstName: | SHIVANI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 850001 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328850001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212686111 | ||||||||
| FaxNumber: | 3212680125 | ||||||||
| Practice Location | |||||||||
| Address1: | 5005 PORT ST JOHN PKWY | ||||||||
| Address2: | 2500 | ||||||||
| City: | PORT ST JOHN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329274305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216900164 | ||||||||
| FaxNumber: | 3216902591 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2005 | ||||||||
| LastUpdateDate: | 08/23/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME101697 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 000036200 | 05 | FL | MEDICAID |