Provider Demographics
NPI:1255685137
Name:MISHRA, SHASHWAT (MD)
Entity Type:Individual
Prefix:DR
First Name:SHASHWAT
Middle Name:
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:A 13, NIRBHAYNAGAR
Mailing Address - Street 2:BYE PASS GAILANA ROAD
Mailing Address - City:AGRA
Mailing Address - State:UTTAR PRADESH
Mailing Address - Zip Code:282007
Mailing Address - Country:IN
Mailing Address - Phone:0091981-166-3872
Mailing Address - Fax:
Practice Address - Street 1:225 E CHICAGO AVE
Practice Address - Street 2:SUITE 17462
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2991
Practice Address - Country:US
Practice Address - Phone:501-786-4184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-31
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125062477207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery