Healthcare Provider Details

I. General information

NPI: 1235464306
Provider Name (Legal Business Name): SIDDHARTHA MITRA MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2009
Last Update Date: 02/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1545 DIVISADERO ST SECOND FLOOR
SAN FRANCISCO CA
94115-3425
US

IV. Provider business mailing address

1545 DIVISADERO ST SECOND FLOOR
SAN FRANCISCO CA
94115-3425
US

V. Phone/Fax

Practice location:
  • Phone: 415-353-7900
  • Fax: 415-353-2640
Mailing address:
  • Phone: 415-353-7900
  • Fax: 415-353-2640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA115757
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: