Provider Demographics
NPI:1194821504
Name:MISHRA, SANJAY K (MD)
Entity Type:Individual
Prefix:
First Name:SANJAY
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 1:1415 LILAC DR N STE 190
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4544
Mailing Address - Country:US
Mailing Address - Phone:763-267-8701
Mailing Address - Fax:
Practice Address - Street 1:1415 LILAC DR N STE 190
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-4544
Practice Address - Country:US
Practice Address - Phone:763-267-8701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN40500207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNG67932Medicare UPIN
MN010000193Medicare ID - Type Unspecified