Healthcare Provider Details

I. General information

NPI: 1306022678
Provider Name (Legal Business Name): PAYAL BANSAL MITTAL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2008
Last Update Date: 12/06/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S MAIN ST SUITE 101
ORANGE CA
92868-4507
US

IV. Provider business mailing address

500 S MAIN ST SUITE 101
ORANGE CA
92868-4507
US

V. Phone/Fax

Practice location:
  • Phone: 714-836-4204
  • Fax:
Mailing address:
  • Phone: 714-836-4204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberA113174
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: