Provider Demographics
NPI:1619084639
Name:MISENAR, GARIK T (MD)
Entity Type:Individual
Prefix:
First Name:GARIK
Middle Name:T
Last Name:MISENAR
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 5576
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37602-5576
Mailing Address - Country:US
Mailing Address - Phone:423-926-6266
Mailing Address - Fax:423-926-7599
Practice Address - Street 1:400 N STATE OF FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6035
Practice Address - Country:US
Practice Address - Phone:423-926-6266
Practice Address - Fax:423-926-7599
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101242546207P00000X
TNMD39742207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1619084639Medicaid
TN3332120Medicaid
P00224900OtherRR MEDICARE
TN3332120Medicaid
TN103I930177Medicare PIN
P00224900OtherRR MEDICARE