Basic Information
| Provider Information | |||||||||
| NPI: | 1235576836 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MITRA | ||||||||
| FirstName: | SHIMONTINI | ||||||||
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| Credential: | MBCHB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1340 BOYLSTON ST | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022154302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6179276000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 330 BROOKLINE AVE | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176677000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2013 | ||||||||
| LastUpdateDate: | 08/08/2018 | ||||||||
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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 | 207RN0300X | 273856 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
No ID Information.