Healthcare Provider Details

I. General information

NPI: 1992828396
Provider Name (Legal Business Name): BASANT K. MITTAL, M.D. P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3032 N. SUSQUEHANNA TRAIL ROUTES 11 AND 15
SHAMOKIN DAM PA
17876-0429
US

IV. Provider business mailing address

PO BOX 429 3032 N. SUSQUEHANNA TRAIL-ROUTES 11 AND 15
SHAMOKIN DAM PA
17876-0429
US

V. Phone/Fax

Practice location:
  • Phone: 570-743-5020
  • Fax: 570-743-4505
Mailing address:
  • Phone: 570-743-5020
  • Fax: 570-743-4505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberMD-039080-L
License Number StatePA

VIII. Authorized Official

Name: DR. BASANT KUMAR MITTAL
Title or Position: PRESIDENT
Credential: M.D.
Phone: 570-743-5020