Provider Demographics
NPI:1134114614
Name:MISHKIN, FREDRIC R (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDRIC
Middle Name:R
Last Name:MISHKIN
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 1:135 W RAVINE RD
Mailing Address - Street 2:SUITE 3A
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3847
Mailing Address - Country:US
Mailing Address - Phone:423-246-6777
Mailing Address - Fax:423-246-7766
Practice Address - Street 1:135 W RAVINE RD
Practice Address - Street 2:SUITE 3A
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3847
Practice Address - Country:US
Practice Address - Phone:423-246-6777
Practice Address - Fax:423-246-7766
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD19796207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006025552Medicaid
VA057653OtherANTHEM
TN100010463OtherPHP TENNCARE
WV1803461000Medicaid
KY64794654Medicaid
KY000000053385OtherANTHEM
TN4675304OtherAETNA
TNTN0103OtherUNITED HEALTHCARE RIVER V
TN3700033Medicaid
TN000127737OtherBCBS OF TN
TN3044499Medicare ID - Type Unspecified
VA057653OtherANTHEM
TN000127737OtherBCBS OF TN