Provider Demographics
NPI:1720011687
Name:MISHRA, SURESH C (MD)
Entity Type:Individual
Prefix:DR
First Name:SURESH
Middle Name:C
Last Name:MISHRA
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 1:3332 17TH ST
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34235-8904
Mailing Address - Country:US
Mailing Address - Phone:941-365-2171
Mailing Address - Fax:
Practice Address - Street 1:3332 17TH ST
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34235-8904
Practice Address - Country:US
Practice Address - Phone:941-365-2171
Practice Address - Fax:941-957-3349
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL54969207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL05372OtherUNIVERSAL PROVIDER ID
FL4285918OtherAETNA PROVIDER ID
FL255810600Medicaid
FL10871OtherBCBS PROVIDER ID
FL05372OtherUNIVERSAL PROVIDER ID
FL10871OtherBCBS PROVIDER ID
FLA78338Medicare UPIN