Healthcare Provider Details

I. General information

NPI: 1710986633
Provider Name (Legal Business Name): SANJAY MITTAL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 08/15/2024
Certification Date: 08/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2817 ROCK MERITT AVENUE
FORT LIBERTY NC
28310-4433
US

IV. Provider business mailing address

WOMACK ARMY MEDICAL CENTER 2817 ROCK MERITT AVENUE
FORT LIBERTY NC
28310-0001
US

V. Phone/Fax

Practice location:
  • Phone: 910-643-9484
  • Fax: 910-907-7956
Mailing address:
  • Phone: 910-907-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number200301148
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier8913435
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: