Healthcare Provider Details

I. General information

NPI: 1083829774
Provider Name (Legal Business Name): SRILAKSHMI MITTA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 DUDLEY ST
PROVIDENCE RI
02905-3233
US

IV. Provider business mailing address

455 TOLL GATE RD PRC AND CREDENTIALING
WARWICK RI
02886
US

V. Phone/Fax

Practice location:
  • Phone: 401-453-7950
  • Fax: 401-453-7748
Mailing address:
  • Phone: 401-273-0641
  • Fax: 401-273-2919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD13002
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: