Provider Demographics
NPI:1003023466
Name:MISHRA, VIJAY (OTR)
Entity Type:Individual
Prefix:MR
First Name:VIJAY
Middle Name:
Last Name:MISHRA
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 CRESTON DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-3261
Mailing Address - Country:US
Mailing Address - Phone:586-872-5133
Mailing Address - Fax:
Practice Address - Street 1:840 CRESTON DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-3261
Practice Address - Country:US
Practice Address - Phone:586-872-5133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201003359225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP10490Medicare UPIN