Provider Demographics
NPI:1306089222
Name:MISHRA, MANISH KUMAR (MD)
Entity type:Individual
Prefix:
First Name:MANISH
Middle Name:KUMAR
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 1:82 TUNNEL RD
Mailing Address - Street 2:
Mailing Address - City:POTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17901-3869
Mailing Address - Country:US
Mailing Address - Phone:570-622-5455
Mailing Address - Fax:570-622-5493
Practice Address - Street 1:700 SCHUYLKILL MANOR RD
Practice Address - Street 2:SUUITE 5A
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-3849
Practice Address - Country:US
Practice Address - Phone:570-516-9444
Practice Address - Fax:570-728-2360
Is Sole Proprietor?:No
Enumeration Date:2009-04-07
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAMD446292207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program