Provider Demographics
NPI:1538198676
Name:MITTAL, SHALINI (MD)
Entity type:Individual
Prefix:
First Name:SHALINI
Middle Name:
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 1:2414 BULL ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-1906
Mailing Address - Country:US
Mailing Address - Phone:803-898-8461
Mailing Address - Fax:803-898-8429
Practice Address - Street 1:2100 BULL ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2104
Practice Address - Country:US
Practice Address - Phone:803-898-8405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21854207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC218543Medicaid
SCH45951Medicare UPIN
SC218543Medicaid
SCH459513357Medicare PIN