Provider Demographics
NPI:1619020849
Name:MISHKIN, MARVIN (MD)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:
Last Name:MISHKIN
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 1:3009 N BALLAS RD
Mailing Address - Street 2:SUITE 105B
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2322
Mailing Address - Country:US
Mailing Address - Phone:314-432-2323
Mailing Address - Fax:314-432-5328
Practice Address - Street 1:3009 N BALLAS RD
Practice Address - Street 2:SUITE 105B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2322
Practice Address - Country:US
Practice Address - Phone:314-432-2323
Practice Address - Fax:314-432-5328
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR2291174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO18457OtherBCBS OF MO (ANTHEM)
43092556563080A001OtherWPS TRICARE
MO2282056002OtherCIGNA
MO4134393OtherAETNA
MOA12810OtherMERCY HEALTH PLANS
MO090026OtherUNITED HEALTHCARE
130817OtherHEALTHLINK
MO2162OtherGROUP HEALTH PLAN
43092556563080A001OtherWPS TRICARE