Healthcare Provider Details

I. General information

NPI: 1548272107
Provider Name (Legal Business Name): KSHITIJ P MISTRY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 11/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 BLYTHE BLVD MEDICAL CENTER PLAZA, SUITE 200
CHARLOTTE NC
28203-5866
US

IV. Provider business mailing address

PO BOX 601372
CHARLOTTE NC
28260-1372
US

V. Phone/Fax

Practice location:
  • Phone: 704-381-8840
  • Fax: 704-381-8848
Mailing address:
  • Phone: 704-381-8840
  • Fax: 704-381-8848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number2004-01098
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: