Healthcare Provider Details

I. General information

NPI: 1992742084
Provider Name (Legal Business Name): VIMAL MITTAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 11/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 W HIGHLAND BLVD
INVERNESS FL
34452-4720
US

IV. Provider business mailing address

PO BOX 741087
ATLANTA GA
30384-1087
US

V. Phone/Fax

Practice location:
  • Phone: 352-726-0422
  • Fax: 352-341-6121
Mailing address:
  • Phone: 954-777-0018
  • Fax: 866-262-5507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License NumberME120312
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207ZF0201X
TaxonomyForensic Pathology Physician
License NumberME120312
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberME120312
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: