=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235136094
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MITHLESH GOVIL M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2005
-----------------------------------------------------
Last Update Date | 06/25/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 196 PARKWAY S SUITE 303
-----------------------------------------------------
City | WATERFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06385-1234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-443-4455
-----------------------------------------------------
Fax | 860-447-8961
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 196 PARKWAY S SUITE 304
-----------------------------------------------------
City | WATERFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06385-1234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-442-7027
-----------------------------------------------------
Fax | 866-861-9119
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RH0003X
-----------------------------------------------------
Taxonomy Name | Hematology & Oncology Physician
-----------------------------------------------------
License Number | 021686
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 021686
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------