MEDICARE: SHIVANI MITRA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	ME101697	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1245224518
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHIVANI MITRA MD

Provider Business Mailing Address
First Line	:	PO BOX 850001
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32885-0001
Country	:	US
Telephone Number	:	321-268-6111
Fax Number	:	321-268-0125

Provider Business Practice Location Address
First Line	:	5005 PORT ST JOHN PKWY
Second Line	:	2500
City	:	PORT ST JOHN
State	:	FL
Zip	:	32927-4305
Country	:	US
Telephone Number	:	321-690-0164
Fax Number	:	321-690-2591

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/01/2005
Last Update Date	:	08/23/2010

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Directions to “ SHIVANI MITRA MD” Practice Location

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