Provider Demographics
NPI:1164475877
Name:MISRA, VIJAY LAXMI (MD)
Entity Type:Individual
Prefix:
First Name:VIJAY LAXMI
Middle Name:
Last Name:MISRA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 FRANKLIN AVE STE 4800
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-3595
Mailing Address - Country:US
Mailing Address - Phone:309-454-5900
Mailing Address - Fax:309-454-2820
Practice Address - Street 1:1302 FRANKLIN AVE STE 4800
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-3595
Practice Address - Country:US
Practice Address - Phone:309-454-5900
Practice Address - Fax:309-454-2820
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036126566207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036126566Medicaid