Provider Demographics
NPI:1386641728
Name:MISHRA, SHASHANK (MD)
Entity Type:Individual
Prefix:MR
First Name:SHASHANK
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:PO BOX 601843
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1843
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4815 BEREWICK TOWN CENTER DR STE C&D
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28278-6733
Practice Address - Country:US
Practice Address - Phone:980-337-4652
Practice Address - Fax:980-337-4653
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2003-01021207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1359AOtherBCBS PROVIDER NUMBER
NC891359AMedicaid
NC891359AMedicaid
NC2023092AMedicare ID - Type UnspecifiedMEDICARE CIGNA PROV NUM