Provider Demographics
NPI:1548224306
Name:MITTAL, RAJ R (MD)
Entity type:Individual
Prefix:DR
First Name:RAJ
Middle Name:R
Last Name:MITTAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6419 W 87TH ST
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-1072
Mailing Address - Country:US
Mailing Address - Phone:708-233-5636
Mailing Address - Fax:708-233-5649
Practice Address - Street 1:6419 W 87TH ST
Practice Address - Street 2:SUITE 1
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-1072
Practice Address - Country:US
Practice Address - Phone:708-233-5636
Practice Address - Fax:708-233-5649
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD16181Medicare UPIN
IL757201Medicare ID - Type Unspecified