Basic Information
| Provider Information | |||||||||
| NPI: | 1376885533 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITTAL | ||||||||
| FirstName: | JAIMIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHAH | ||||||||
| OtherFirstName: | JAIMIE | ||||||||
| OtherMiddleName: | JAGDISH | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 801 OSTRUM ST | ||||||||
| Address2: | |||||||||
| City: | BETHLEHEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180151000 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 701 OSTRUM ST STE 103 | ||||||||
| Address2: | |||||||||
| City: | FOUNTAIN HILL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 18015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4845266200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2013 | ||||||||
| LastUpdateDate: | 08/02/2018 | ||||||||
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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 | 207R00000X | MD463946 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RI0200X | MD463946 | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
No ID Information.