Healthcare Provider Details

I. General information

NPI: 1528220720
Provider Name (Legal Business Name): MANOJ MITTAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2008
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 L ST STE 500
SACRAMENTO CA
95816-5616
US

IV. Provider business mailing address

10470 OLD PLACERVILLE RD, STE 100
SACRAMENTO CA
95827-2539
US

V. Phone/Fax

Practice location:
  • Phone: 916-454-6850
  • Fax: 916-454-6852
Mailing address:
  • Phone: 800-470-0071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number94-7047
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number54526
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMN
# 4
Primary TaxonomyY
Taxonomy Code2084A2900X
TaxonomyNeurocritical Care Physician
License NumberA146354
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: