Basic Information
| Provider Information | |||||||||
| NPI: | 1760625552 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MISTRY | ||||||||
| FirstName: | SIMA | ||||||||
| MiddleName: | GOPAL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3360 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8663662983 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11603 STATE AVE STE G | ||||||||
| Address2: | PROVIDENCE MEDICAL GROUP MARYSVILLE CLINIC | ||||||||
| City: | MARYSVILLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982718465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606586800 | ||||||||
| FaxNumber: | 3606586819 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2009 | ||||||||
| LastUpdateDate: | 02/18/2015 | ||||||||
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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 | 60403767 | WA | Y | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | 60403767 | WA | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1926710 | 05 | LA | MEDICAID | MD60403767 | 01 | WA | WSL | OTHER |