1306836952 NPI number — POONAM MISHRA D.O.

Table of content: POONAM MISHRA D.O. (NPI 1306836952)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306836952 NPI number — POONAM MISHRA D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MISHRA
Provider First Name:
POONAM
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306836952
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/06/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
401 N WICKHAM RD
Provider Second Line Business Mailing Address:
SUITE H
Provider Business Mailing Address City Name:
MELBOURNE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32935-8659
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-757-5105
Provider Business Mailing Address Fax Number:
321-757-5104

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 N WICKHAM RD
Provider Second Line Business Practice Location Address:
SUITE H
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32935-8659
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-757-5105
Provider Business Practice Location Address Fax Number:
321-757-5104
Provider Enumeration Date:
10/25/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207QA0505X , with the licence number:  593360315 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 40462 . This is a "BCBS MAB GROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 57174 . This is a "BCBS PROVIDER ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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