Provider Demographics
NPI:1649407578
Name:DEWAN, MISHA (MD)
Entity Type:Individual
Prefix:DR
First Name:MISHA
Middle Name:
Last Name:DEWAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5501 OLD YORK ROAD
Mailing Address - Street 2:KORMAN-SUITE 202
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19141-3018
Mailing Address - Country:US
Mailing Address - Phone:215-254-2612
Mailing Address - Fax:215-456-5926
Practice Address - Street 1:1200 W TABOR ROAD
Practice Address - Street 2:4TH FLOOR-MOSS BUILDING
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3019
Practice Address - Country:US
Practice Address - Phone:215-456-6815
Practice Address - Fax:215-456-6803
Is Sole Proprietor?:No
Enumeration Date:2009-06-18
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN53310207L00000X
PAMD448671207L00000X, 207LP2900X
PAMT194659207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MNENROLLEDMedicaid