Provider Demographics
NPI:1558413849
Name:MISSRY, JOHN JACOB (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JACOB
Last Name:MISSRY
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 1:5701 CENTRE AVE
Mailing Address - Street 2:SUITE L-3
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15206-3744
Mailing Address - Country:US
Mailing Address - Phone:412-661-2100
Mailing Address - Fax:412-661-3930
Practice Address - Street 1:5701 CENTRE AVE
Practice Address - Street 2:SUITE L-3
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15206-3744
Practice Address - Country:US
Practice Address - Phone:412-661-2100
Practice Address - Fax:412-661-3930
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD048849L207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP00291805Medicare PIN
F98278Medicare UPIN
PA603732UM5Medicare PIN
PA603732Medicare PIN