Healthcare Provider Details

I. General information

NPI: 1366476319
Provider Name (Legal Business Name): PRABHAS MITTAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 10/01/2020
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 W WISCONSIN AVE NEOPLASTIC DISEASES
MILWAUKEE WI
53226-3522
US

IV. Provider business mailing address

9200 W WISCONSIN AVE NEOPLASTIC DISEASES
MILWAUKEE WI
53226-3522
US

V. Phone/Fax

Practice location:
  • Phone: 414-805-6800
  • Fax: 414-805-0618
Mailing address:
  • Phone: 414-805-6800
  • Fax: 414-805-0618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberMD00041314
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number50320
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: