MEDICARE: DR. SHYAMAL K 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	207RC0000X	Cardiovascular Disease Physician	0035439	NC
2	207RS0012X	Sleep Medicine (Internal Medicine) Physician	00-35439	NC
3	207U00000X	Nuclear Medicine Physician	0035439	NC
4	207UN0901X	Nuclear Cardiology Physician	0035439	NC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	060030036	OTHER		RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	59825	OTHER	NC	BCBS OF NC
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1467437079
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHYAMAL K MITRA MD

Provider Business Mailing Address
First Line	:	3280 HENDERSON DR STE C
Second Line	:
City	:	JACKSONVILLE
State	:	NC
Zip	:	28546-5290
Country	:	US
Telephone Number	:	910-915-8450
Fax Number	:	888-745-7026

Provider Business Practice Location Address
First Line	:	3280 HENDERSON DR STE C
Second Line	:
City	:	JACKSONVILLE
State	:	NC
Zip	:	28546-5290
Country	:	US
Telephone Number	:	910-915-8450
Fax Number	:	888-745-7026

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

Provider Enumeration Date	:	12/07/2005
Last Update Date	:	08/02/2023

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