Basic Information
| Provider Information | |||||||||
| NPI: | 1124266366 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MITRA | ||||||||
| FirstName: | TITHI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8000 | ||||||||
| Address2: | DEPT 596 | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142670002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662950041 | ||||||||
| FaxNumber: | 7325577109 | ||||||||
| Practice Location | |||||||||
| Address1: | 368 LAKEHURST RD | ||||||||
| Address2: | SUITE 207 | ||||||||
| City: | TOMS RIVER | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 087557339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7325576222 | ||||||||
| FaxNumber: | 7325576227 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2009 | ||||||||
| LastUpdateDate: | 02/13/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 25MA09322600 | NJ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 267178 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 03512810 | 05 | NY | MEDICAID | 0386146 | 05 | NJ | MEDICAID |