Provider Demographics
NPI:1710977723
Name:MISHRA, MITHILESH J (MD)
Entity Type:Individual
Prefix:DR
First Name:MITHILESH
Middle Name:J
Last Name:MISHRA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1400 MICHIGAN ST SE STE 2S
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503
Mailing Address - Country:US
Mailing Address - Phone:616-454-5278
Mailing Address - Fax:616-454-4030
Practice Address - Street 1:1400 MICHIGAN ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2032
Practice Address - Country:US
Practice Address - Phone:616-454-5278
Practice Address - Fax:616-454-4030
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-21
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMM0430372086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1540509Medicaid
MIA75889Medicare UPIN