Provider Demographics
NPI:1003832817
Name:MISTRETTA, MICHAEL A (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:MISTRETTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1000 BOULDERS PKWY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23225-5545
Mailing Address - Country:US
Mailing Address - Phone:804-320-4243
Mailing Address - Fax:804-282-1486
Practice Address - Street 1:6600 W BROAD ST STE 300
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-1709
Practice Address - Country:US
Practice Address - Phone:804-320-4243
Practice Address - Fax:804-622-0552
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101052617207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA80057OtherSOUTHER HEALTH PROVIDER #
VA12178OtherCARENET PROVIDER NUMBER
VA005812682Medicaid
VA021790OtherCIGNA PROVIDER NUMBER
VA4800040OtherUNITED HEALTHCARE PROV #
VA223643OtherANTHEM
VA557515OtherAETNA
VA7044153OtherMAMSI PROVIDER NUMBER
VA7044153OtherMAMSI PROVIDER NUMBER
VA80057OtherSOUTHER HEALTH PROVIDER #