Provider Demographics
NPI:1972581924
Name:MISHRA, KAMLA K (MD)
Entity type:Individual
Prefix:DR
First Name:KAMLA
Middle Name:K
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:SUITE 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:2006-01-09
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD059125L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015971720002Medicaid
PA50070589OtherKEYSTONE SPECIALIST
PA50070589OtherKEYSTONE
PACB00663OtherRAILROAD MEDICARE PBA
PA0015971720004OtherMA
PACB00663OtherRAILROAD MEDICARE PBA
PA892960Medicare PIN