Basic Information
Provider Information
NPI: 1255482394
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MITTAL
FirstName: BAHAR
MiddleName:  
NamePrefix: DR.
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 635283
Address2:  
City: CINCINNATI
State: OH
PostalCode: 452635283
CountryCode: US
TelephoneNumber: 8599127211
FaxNumber: 8596558981
Practice Location
Address1: 125 SAINT MICHAEL DR
Address2:  
City: COLD SPRING
State: KY
PostalCode: 41076
CountryCode: US
TelephoneNumber: 8597814111
FaxNumber: 8594415214
Other Information
ProviderEnumerationDate: 01/16/2007
LastUpdateDate: 09/04/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000X38913KYY Allopathic & Osteopathic PhysiciansFamily Medicine 

ID Information
IDTypeStateIssuerDescription
6411452305KY MEDICAID
P0145974101KYRR MEDICAREOTHER
00000036359801KYBLUESHIELD NUMBEROTHER
011843205OH MEDICAID


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