Provider Demographics
NPI:1306836952
Name:MISHRA, POONAM (DO)
Entity Type:Individual
Prefix:
First Name:POONAM
Middle Name:
Last Name:MISHRA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 N WICKHAM RD
Mailing Address - Street 2:SUITE H
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-8659
Mailing Address - Country:US
Mailing Address - Phone:321-757-5105
Mailing Address - Fax:321-757-5104
Practice Address - Street 1:401 N WICKHAM RD
Practice Address - Street 2:SUITE H
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-8659
Practice Address - Country:US
Practice Address - Phone:321-757-5105
Practice Address - Fax:321-757-5104
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL593360315207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL40462OtherBCBS MAB GROUP
FL57174OtherBCBS PROVIDER ID
FL57174OtherBCBS PROVIDER ID
FL40462OtherBCBS MAB GROUP