1780648048 NPI number — VIRENDRA K MISRA MD

Table of content: VIRENDRA K MISRA MD (NPI 1780648048)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780648048 NPI number — VIRENDRA K MISRA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MISRA
Provider First Name:
VIRENDRA
Provider Middle Name:
K
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:
1780648048
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 639
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
THIENSVILLE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53092-0639
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-247-9005
Provider Business Mailing Address Fax Number:
414-247-9004

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2603 W RAWSON AVE
Provider Second Line Business Practice Location Address:
SUITE 128
Provider Business Practice Location Address City Name:
OAK CREEK
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53154-8422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-431-6760
Provider Business Practice Location Address Fax Number:
414-431-6761
Provider Enumeration Date:
04/13/2006

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: 2084N0400X , with the licence number:  38580 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000001093 . This is a "MEDICARE PTAN" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 32336900 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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