Healthcare Provider Details

I. General information

NPI: 1639497514
Provider Name (Legal Business Name): MITESH S BHALALA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2010
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 SUMMER ST
TAUNTON MA
02780-3469
US

IV. Provider business mailing address

189 QUINCY ST
BROCKTON MA
02302-2967
US

V. Phone/Fax

Practice location:
  • Phone: 508-821-4100
  • Fax: 508-822-2367
Mailing address:
  • Phone: 508-588-6700
  • Fax: 508-584-3010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number266145
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: