Provider Demographics
NPI:1003803594
Name:MISHRA, UMA BALLAVA (MD)
Entity Type:Individual
Prefix:
First Name:UMA
Middle Name:BALLAVA
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 1:2565 ROUTE 9W
Mailing Address - Street 2:
Mailing Address - City:CORNWALL
Mailing Address - State:NY
Mailing Address - Zip Code:12518-1309
Mailing Address - Country:US
Mailing Address - Phone:845-534-4700
Mailing Address - Fax:845-534-4800
Practice Address - Street 1:2565 ROUTE 9W
Practice Address - Street 2:
Practice Address - City:CORNWALL
Practice Address - State:NY
Practice Address - Zip Code:12518-1309
Practice Address - Country:US
Practice Address - Phone:845-534-4700
Practice Address - Fax:845-534-4800
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1356911174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00960843Medicaid
NY00960843Medicaid
NY70D796T901Medicare PIN