1366443863 NPI number — PREM SHANKER MISRA MD

Table of content: PREM SHANKER MISRA MD (NPI 1366443863)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366443863 NPI number — PREM SHANKER MISRA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MISRA
Provider First Name:
PREM
Provider Middle Name:
SHANKER
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1366443863
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
115 CHERRYWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW HYDE PARK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11040-2209
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-352-2025
Provider Business Mailing Address Fax Number:
516-352-2025

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11247 QUEENS BLVD
Provider Second Line Business Practice Location Address:
STE 108
Provider Business Practice Location Address City Name:
FOREST HILLS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11375-7417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-793-3838
Provider Business Practice Location Address Fax Number:
516-352-2025
Provider Enumeration Date:
08/09/2005

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: 207R00000X , with the licence number:  109522 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207RG0100X , with the licence number: 109522 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 89979 . This is a "GHI MEDICARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00194312 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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