Provider Demographics
NPI:1366443863
Name:MISRA, PREM SHANKER (MD)
Entity Type:Individual
Prefix:
First Name:PREM
Middle Name:SHANKER
Last Name:MISRA
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 1:115 CHERRYWOOD DR
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-2209
Mailing Address - Country:US
Mailing Address - Phone:516-352-2025
Mailing Address - Fax:516-352-2025
Practice Address - Street 1:11247 QUEENS BLVD
Practice Address - Street 2:STE 108
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-7417
Practice Address - Country:US
Practice Address - Phone:718-793-3838
Practice Address - Fax:516-352-2025
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY109522207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY89979OtherGHI MEDICARE
NY00194312Medicaid
B18837Medicare UPIN
NY89979OtherGHI MEDICARE