Provider Demographics
NPI:1215973540
Name:MISHRA, BIBHUTI B (MD)
Entity type:Individual
Prefix:
First Name:BIBHUTI
Middle Name:B
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:PO BOX 791093
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21279-1093
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6845 ELM ST STE 700
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-3851
Practice Address - Country:US
Practice Address - Phone:703-356-1105
Practice Address - Fax:703-356-0970
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010470212084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007101741Medicaid
VA512146M59Medicare ID - Type Unspecified
VA007101741Medicaid
F4404Medicare UPIN