Basic Information
| Provider Information | |||||||||
| NPI: | 1588084974 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MITTAPALLI | ||||||||
| FirstName: | BHARATH | ||||||||
| MiddleName: | KUMAR | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 285 DAVIDSON AVE STE 204 | ||||||||
| Address2: | |||||||||
| City: | SOMERSET | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088734153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322711400 | ||||||||
| FaxNumber: | 7322713544 | ||||||||
| Practice Location | |||||||||
| Address1: | 285 DAVIDSON AVE STE 204 | ||||||||
| Address2: | |||||||||
| City: | SOMERSET | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088734153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322711400 | ||||||||
| FaxNumber: | 7322713544 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2014 | ||||||||
| LastUpdateDate: | 09/09/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 25MA10300600 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 654779 | 05 | NJ | MEDICAID |