Healthcare Provider Details

I. General information

NPI: 1598049702
Provider Name (Legal Business Name): MITALI CHUMKI MITRA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2011
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8530 LA MESA BLVD STE 200
LA MESA CA
91942-0966
US

IV. Provider business mailing address

823 GATEWAY CENTER WAY
SAN DIEGO CA
92102-4541
US

V. Phone/Fax

Practice location:
  • Phone: 619-515-2585
  • Fax:
Mailing address:
  • Phone: 619-515-2300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC54133
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: