Healthcare Provider Details

I. General information

NPI: 1518397587
Provider Name (Legal Business Name): CAROLINA CARDIOLOGY, SLEEP & OBESITY CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2013
Last Update Date: 09/12/2022
Certification Date: 09/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3280 HENDERSON DR STE C
JACKSONVILLE NC
28546-5290
US

IV. Provider business mailing address

3280 HENDERSON DR STE C
JACKSONVILLE NC
28546-5290
US

V. Phone/Fax

Practice location:
  • Phone: 910-915-8450
  • Fax:
Mailing address:
  • Phone: 910-915-8450
  • Fax: 888-745-7026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RB0002X
TaxonomyObesity Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number00-35439
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number00-35439
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number00-35439
License Number StateNC
# 7
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SHYAMAL KISHORE MITRA
Title or Position: OWNER
Credential: M.D.
Phone: 252-525-3290