Provider Demographics
NPI:1326092362
Name:MISRA, SUBHASREE (MD)
Entity Type:Individual
Prefix:
First Name:SUBHASREE
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:PO BOX 423
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311-0423
Mailing Address - Country:US
Mailing Address - Phone:708-872-4711
Mailing Address - Fax:708-872-4714
Practice Address - Street 1:19404 N CREEK DRIVE
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:IL
Practice Address - Zip Code:60411
Practice Address - Country:US
Practice Address - Phone:708-872-4711
Practice Address - Fax:708-872-4714
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361065962084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01615936OtherBLUE SHIELD
IL01615936OtherBLUE SHIELD
IL603770Medicare ID - Type Unspecified