Provider Demographics
NPI:1700053469
Name:MISHRA, MICKY (MD)
Entity Type:Individual
Prefix:DR
First Name:MICKY
Middle Name:
Last Name:MISHRA
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:PO BOX 809
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-0809
Mailing Address - Country:US
Mailing Address - Phone:404-994-4561
Mailing Address - Fax:404-994-4562
Practice Address - Street 1:1400 NORTHSIDE FORSYTH DR
Practice Address - Street 2:STE 390
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-6018
Practice Address - Country:US
Practice Address - Phone:404-994-4561
Practice Address - Fax:404-994-4562
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-13
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35090306207RC0000X
GA61127207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003171600AMedicaid
GA003171600AMedicaid