Provider Demographics
NPI:1730208810
Name:MISTRY, JIMMY (M D)
Entity type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:
Last Name:MISTRY
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93 W FOURTH ST STE B
Mailing Address - Street 2:
Mailing Address - City:SUTTONS BAY
Mailing Address - State:MI
Mailing Address - Zip Code:49682-8408
Mailing Address - Country:US
Mailing Address - Phone:231-271-2002
Mailing Address - Fax:
Practice Address - Street 1:93 W FOURTH ST STE B
Practice Address - Street 2:
Practice Address - City:SUTTONS BAY
Practice Address - State:MI
Practice Address - Zip Code:49682-8408
Practice Address - Country:US
Practice Address - Phone:231-271-2002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301031744207Q00000X, 207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Not Answered207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1036581Medicaid
MI0585916Medicare ID - Type Unspecified
MIA17131Medicare UPIN