Healthcare Provider Details

I. General information

NPI: 1528062221
Provider Name (Legal Business Name): RAMAN L. MITRA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 07/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 N MICHIGAN ST SUITE 400
SOUTH BEND IN
46601-1077
US

IV. Provider business mailing address

610 N MICHIGAN ST SUITE 400
SOUTH BEND IN
46601-1077
US

V. Phone/Fax

Practice location:
  • Phone: 574-647-8120
  • Fax: 574-647-8111
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number01045628A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: