NPIMap

Individual provider Active NPI

Deepak Mitra, MD

  • Internal Medicine Physician
  • McHenry, IL
National Provider Identifier
1114068467
Registry record updated Apr 19, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
License
036-122249 Issued in IL
Practice address
633 Ridgeview Dr
McHenry, IL 60050-7012
Phone
(815) 344-2760
Fax
(815) 344-0664
NPI assigned
Feb 9, 2007
Last updated
Apr 19, 2022By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Apr 19, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine Physician 207R00000X 49813 MN
Internal Medicine Physician 207R00000X 036-122249 IL Primary

Addresses

Primary practice location

633 Ridgeview Dr
McHenry, IL 60050-7012

Mailing address

633 Ridgeview Dr
McHenry, IL 60050-7012
Phone (815) 344-2760

Other identifiers 3

IdentifierTypeStateIssuer
552920000MedicaidMN
P00684628CG6042OtherILRR MEDICARE
MITRADEEOtherWIMERCYCARE INSURANCE

Electronic endpoints 2

TypeEndpointUseAffiliation
FHIR URL https://EpicFHIR.aurora.org/FHIR/MYAURORA/api/FHIR/DSTU2/
Direct Messaging Address dmitra205186@direct.myadvocateaurora.org Direct

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20090114000311 IL Practitioner - Internal Medicine 0941391841 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Internal Medicine
Education
Other, 2005
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices

Practice addresses (Care Compare)

214 McHenry Rd
Buffalo Grove, IL 60089-6748
Phone (847) 459-1160

450 W Hwy 22
Neonatology
Barrington, IL 60010-1919
Phone (847) 381-0123

633 Ridgeview Dr
McHenry, IL 60050-7012
Phone (815) 344-0621

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
036-122249ILMDInternal Medicine Physician
103116MNMDPediatric Occupational Therapist

Practice roles

OrganizationSpecialtyStatusNew patients
Advocate Health and Hospitals Corporation CurrentSince Jan 5, 2015 Accepting new patients
Advocate Health and Hospitals Corporation CurrentSince Jan 5, 2015 Accepting new patients

Locations

214 McHenry Rd
Buffalo Grove, IL 60089
Phone (847) 459-1160

29373 Network Pl
Chicago, IL 60673

633 Ridgeview Dr
McHenry, IL 60050
Phone (815) 344-0621

Organizations & group practices 2

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 10

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1170979200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1650326400000",
    "number": "1114068467",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "633 RIDGEVIEW DR",
            "city": "MCHENRY",
            "state": "IL",
            "postal_code": "600507012",
            "telephone_number": "815-344-2760",
            "fax_number": "815-344-0664"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "633 RIDGEVIEW DR",
            "city": "MCHENRY",
            "state": "IL",
            "postal_code": "600507012",
            "telephone_number": "815-344-2760",
            "fax_number": "815-344-0664"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "MITRA",
        "first_name": "DEEPAK",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2007-02-09",
        "last_updated": "2022-04-19",
        "certification_date": "2022-04-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "MN",
            "license": "49813",
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "IL",
            "license": "036-122249",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "552920000",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RR MEDICARE",
            "identifier": "P00684628CG6042",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MERCYCARE INSURANCE",
            "identifier": "MITRADEE",
            "state": "WI"
        }
    ],
    "endpoints": [
        {
            "endpointType": "FHIR",
            "endpointTypeDescription": "FHIR URL",
            "endpoint": "https://EpicFHIR.aurora.org/FHIR/MYAURORA/api/FHIR/DSTU2/",
            "affiliation": "N",
            "address_1": "633 Ridgeview Dr",
            "city": "McHenry",
            "state": "IL",
            "country_code": "US",
            "postal_code": "600507012",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "dmitra205186@direct.myadvocateaurora.org",
            "affiliation": "N",
            "use": "DIRECT",
            "useDescription": "Direct",
            "address_1": "633 Ridgeview Dr",
            "city": "McHenry",
            "state": "IL",
            "country_code": "US",
            "postal_code": "600507012",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in McHenry, IL

Sources for this page

Verify at the official NPI Registry.