Provider Demographics
NPI:1548272107
Name:MISTRY, KSHITIJ P (MD)
Entity type:Individual
Prefix:
First Name:KSHITIJ
Middle Name:P
Last Name:MISTRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 601372
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1372
Mailing Address - Country:US
Mailing Address - Phone:704-381-8840
Mailing Address - Fax:704-381-8848
Practice Address - Street 1:1001 BLYTHE BLVD
Practice Address - Street 2:MEDICAL CENTER PLAZA, SUITE 200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5866
Practice Address - Country:US
Practice Address - Phone:704-381-8840
Practice Address - Fax:704-381-8848
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2004-010982080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1548272107Medicaid
SCQ0109CMedicaid
NC136VHOtherBCBS
NC79136VHMedicaid
NC136VHOtherBCBS
NC79136VHMedicaid
NCI16573Medicare UPIN
NC2032287CMedicare PIN