Provider Demographics
NPI:1104801232
Name:MISHRA, NILAMADHAB (MD)
Entity type:Individual
Prefix:
First Name:NILAMADHAB
Middle Name:
Last Name:MISHRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 EXECUTIVE PARK BLVD STE 601
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1548
Mailing Address - Country:US
Mailing Address - Phone:336-955-1838
Mailing Address - Fax:336-955-1842
Practice Address - Street 1:275 EXECUTIVE PARK BLVD STE 601
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103
Practice Address - Country:US
Practice Address - Phone:336-955-1838
Practice Address - Fax:336-955-1842
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-13
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200000903207RR0500X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H41196Medicare UPIN
NC2289650AMedicare PIN
7918330OtherAETNA
NC1067783OtherUNITEDHEALTHCARE
NC14190OtherMEDCOST
NC2289650AMedicare PIN
NC129CVOtherBCBS
NC2289650AMedicare PIN
NC129CVOtherBCBS
NC43240OtherPARTNERS
VA5885949Medicaid